Deliberation on Vote 6: Health and Wellness

Meeting report

Opening remarks

The Chairperson noted with appreciation an increase in the Vote 6 allocation, recognising its significance for a department that was already under pressure. He observed that this particular vote included more annexures than most of the votes, which might extend the meeting beyond the scheduled time. To manage the workload efficiently, the Chairperson suggested reviewing the content from pages 101 to 121 on a page-by-page basis. For the annexures, from pages 122 to 154, Members could raise specific points of interest for discussion. He reminded Members of the time constraints but encouraged them to do justice to the task at hand. Any unresolved matters could be incorporated into Committee deliberations during future meetings.

Minister’s opening remarks

Ms Mireille Wenger, Provincial Minister, Western Cape Department of Health and Wellness, stated that the proposed additional appropriation amounted to R197.7 million. She noted that the Committee was already familiar with the Department's budget pressures, particularly those related to goods and services, as these had been presented in a recent briefing. She emphasised that the additional allocation would be instrumental in alleviating in-year pressures, particularly on the goods and services front.

Head of Department’s opening remarks

Dr Keith Cloete, Head of Department (HOD), Western Cape Department of Health and Wellness, explained that the budget increase would be primarily allocated to mitigate challenges in major service areas. Specifically, Programme 2, which covers district health services divided between rural and metro regions, would receive funding to alleviate specific pressures. Additionally, a significant portion was directed to Programme 5, focusing on central hospitals such as Groote Schuur, Tygerberg, and Khayelitsha Hospitals.

He said that some internal adjustments were also being made, with funds also being shifted to other votes, including allocations to the Centre for Data and Informatics (CDI) for a computer refresh and to infrastructure for offsetting specific needs. He mentioned that while the overall additional funding amounted to R197 million, it would play a crucial role in addressing a projected R200 million over-expenditure by the end of October. The allocation was essential in helping the Department break even within the financial year. He also explained that a process was under way to ensure significant savings through March, with the financial adjustments carried into the next fiscal year’s budget. He concluded by assuring the Committee that the details were outlined in the schedule and inviting questions for further clarification.

Deliberation on Vote 6: Health and Wellness in the Schedule to the Western Cape Adjustments Appropriation Bill, 2024

Mr L Van Wyk (DA) referred to Dr Cloete's earlier comments, noting the significant allocations in the budget. He highlighted key figures and pointed out that an additional appropriation of R275 million was allocated for goods and services, while machinery and equipment received nearly R120 million. He identified these as the largest recipients of the funding. He then observed that the most substantial offset against these allocations appeared to be compensation for employees. He requested clarification on this matter, suggesting that further explanation would assist the Committee in understanding and addressing several issues on the table.

Ms R Windvogel (ANC) was worried that rushing through deliberations on a department as critical as this one might reduce the process to a superficial, tick-box exercise, which she deemed unacceptable. She appreciated the increase in the Department’s budget. However, she sought clarity on a point raised by the Finance MEC in the budget speech regarding an allocation of R230 million from the provincial revenue fund. She noted that there was also a mention of R137 million being un-earmarked from the provincial equitable share for the Department’s infrastructure budget to enhance budget flexibility. She requested details on these allocations. How were they reflected in the current budget, and which areas or projects they would target? She further inquired about the implications of un-earmarking the R193 million for infrastructure, and the specific hospitals or projects that would be affected by this adjustment.

On page 104, under Sub-programme 2.1: District Management, Ms Windvogel asked whether the apparent excess funds were available or whether they indicated underspending within the Violence Prevention Unit (VPU).

The Chairperson assured Ms Windvogel that the engagement would not be rushed. He reminded Members that if the Committee could not delve into all the finer details during the meeting, unresolved matters would be included in the resolutions for follow-up in subsequent sessions.

Minister Wenger explained that, as noted in the Finance Minister's budget speech, the Department had actually been allocated R230 million. She clarified that a portion of this allocation would be shifted to other departments for services rendered to the Department of Health. For instance, some funds would be transferred to the Department of the Premier for Information Technology (IT) equipment and licensing fees. After accounting for these shifts and adjustments, the Department was left with R197 million, which was reflected in the current financial records.

She explained that the Provincial Treasury’s decision to un-earmark R137 million of the Department’s infrastructure budget was intended to provide additional flexibility in case the Department faced challenges in managing goods and services pressures, even with the additional appropriation. This un-earmarked amount was a contingency measure, allowing the Department to reallocate funds from infrastructure to other critical areas within the vote if necessary.

Addressing the Compensation of Employees (COE) offset, Minister Wenger noted that stringent rules and regulations from the Department of Public Service and Administration (DPSA) had significantly slowed the Department's ability to fill posts, even those with approved funding. As a result, some of the COE budget remained underutilised, which would help offset pressures on goods and services and on machinery and equipment.

Dr Cloete explained that the Department projects its COE expenditure based on the number of filled posts at any given time, estimating the budget usage until the end of March. During the financial year, two significant factors had impacted COE spending. Firstly, the Department experienced a higher-than-expected attrition rate, with more employees resigning than anticipated. This trend, which was particularly noticeable between July and September, was influenced by several factors, including the dual employment system, although the exact reasons were still under analysis. Secondly, strict regulations had constrained the Department’s ability to fill vacant posts due to austerity measures across government. While recruitment had resumed, delays meant funds allocated for unfilled posts remained unused during the vacancy period. As a result, COE funds for vacant positions were shifted to offset additional expenses in goods and services and in machinery and equipment. This internal adjustment, combined with the additional appropriation, primarily supported these operational needs.

Regarding Programme 2.1 and similar entries in other areas like Programme 1, Dr Cloete clarified that these involved allocations to other votes for services provided. For instance, in the Violence Prevention Programme, posts had been funded and were being filled. However, delays in filling some positions resulted in temporary surpluses, which were used to support related goods and services in other departments. He emphasised that these allocations were essential to ensure continuity and support for collaborative projects such as violence prevention.

Ms Windvogel raised several detailed questions regarding allocations and adjustments in the budget, specifically addressing issues on pages 106 and 107. On Sub-programme 5.1: Central Hospital Services, she highlighted the reallocation of R57 million, which was explained as a “realignment of the main budget funding source to align with the business plan for National Tertiary Services Grant funding within Groote Schuur and Tygerberg Hospitals.” What were the practical implications of this realignment? How might it impact service delivery or operations in these hospitals?

Ms Windvogel also addressed the relocation of R101 million from COE to goods and services. She noted that the stated reason for this adjustment was “cost savings attributed to the ongoing impact of DPSA Circular 49 of 2023,” which introduced measures for fiscal sustainability by controlling the creation and filling of vacant posts. How many posts were affected by these measures and what was the anticipated impact on staffing and service delivery? She urged the Department to avoid attributing blame elsewhere when staff shortages and hiring difficulties arise. She questioned whether these adjustments, including redirecting funds to replace condemned medical equipment, might compromise essential services. She asked the Department for assurance that it had plans to balance these competing priorities without undermining service delivery.

Turning to page 107, under Sub-programme 6.5: Training, she asked how many nursing posts were affected by these budget decisions, and the specific measures implemented to achieve savings. Had these savings resulted from delayed recruitment for vacant posts or other factors?

Mr Van Wyk referred to the reallocation of R15 million under Programme 3, specifically for Emergency Medical Services (EMS), which was intended to partially address service delivery pressures. He requested further clarification on this allocation, particularly in relation to the ongoing pressures faced by EMS. How would this funding assist in alleviating the challenges EMS were experiencing?

Minister Wenger explained that several factors had contributed to the Department's current staffing challenges. She first addressed the issue of post freezes, which had been implemented by the Department. She also mentioned that there had been a higher-than-usual employee attrition rate, with more people resigning than anticipated. The reasons behind this spike in resignations were being investigated, and the Department had gained some insight into why this had occurred, particularly in the past two to three months. In addition to these challenges, stricter regulations were introduced, which made the process of advertising and filling vacant posts more cumbersome. She acknowledged that, given the large size of the Department, which employs 30,000 people, employee turnover was always significant, with many employees retiring or resigning. The new recruitment regulations had made it much more difficult and time-consuming to refill these posts, and the combination of these factors led to staffing delays, even for funded posts. She reassured the Committee that, despite these challenges, the Department was doing everything it could to make the process of filling vacancies as efficient as possible. She emphasised that, due to the sheer scale of the Department and the volume of vacancies, staffing issues had become a considerable challenge, but the Department was making every effort to address them.

Minister Wenger also discussed the impact of the additional appropriation for goods and services, explaining that the adjustment would ensure the Department would not overspend, allowing for more flexibility in making other budget decisions. Finally, she asked Dr Cloete to provide more detailed information on the staffing issues, particularly regarding the nursing posts and other medical staff positions, as well as the other questions raised by Members of the Committee.

Dr Cloete clarified that the Department was doing everything in its power to fill vacant posts, emphasising that no money was being saved by leaving positions unfilled to redirect funds to other areas. He reiterated that the process of filling posts had been significantly slowed down due to stringent regulations from the DPSA, which had imposed new restrictions on the way posts could be advertised. As an example, he described a specific challenge faced by large hospitals like Tygerberg and Groote Schuur, which had traditionally used a “block advert” system to fill entry-level nursing posts. Under the previous system, the Department could keep the advert open and fill posts as applications came in, but the new regulations had removed the ability to use this method. Instead, each post now had to be advertised individually, which meant that the Department had to advertise vacancies nationally and process thousands of applications. This change caused a significant slowdown in the recruitment process.

He said that the Department was working on streamlining the process and was requesting permission from the DPSA to revert to a more efficient system. He acknowledged that the Department faced challenges in filling posts quickly, especially with the unexpected spike in resignations. This led to a situation where, even though posts were funded, it was not possible to fill them in time, resulting in the decision to move funds from the COE budget to offset pressures in other areas.

Regarding the national tertiary services grant mentioned on page 106, he explained that this funding came from a conditional grant rather than voted funds. The Department had made technical adjustments to its business plan to shift money between line items in accordance with the approved budget. Since the funding was part of a conditional grant, the Department had to adhere to the terms of the business plan when making these adjustments.

Dr Cloete also addressed the issue of nursing posts on page 107, specifically mentioning three vacant posts in the West Coast area. He explained that, as part of the training process for nursing staff, the Department would release staff to attend training, and other nurses would fill in for them during their absence. Due to this process, the Department had lost the ability to fill these specific posts, but this was being managed through other means. He assured the Committee that this was a small number of posts, and the broader pool of available nurses could still support the service.

Lastly, he explained that the R15 million allocated to emergency medical services under Programme 3 was intended to alleviate service pressures, particularly related to ambulance response times. While this funding was crucial for maintaining service levels, he emphasised that the Department would not reduce service levels and would instead focus on building capacity for the future.

Ms Windvogel expressed concern about the impact of the vacancies and the lengthy process involved in filling them. The shortage of staff in clinics and hospitals was a significant issue that directly affected the quality of health services. She emphasised that the public did not see the bureaucratic processes involved in filling posts and that, for the people, the most important issue was the provision of services. She appreciated that the HOD mentioned ongoing engagement with the DPSA regarding filling vacancies and the advertising process. However, she made it clear that the current situation was unacceptable, as people in the community needed immediate access to services, not delays caused by administrative procedures.

Minister Wenger acknowledged the concern, adding that she shared the frustration about the current situation. She suggested that the Committee could potentially assist by recommending what would help strengthen their arguments. She recognised that, while the administrative measures were necessary across the public service, they had unintended consequences, especially in frontline service departments like Health. She hoped that everyone could see the negative effects of these measures.

The Chairperson noted the Minister's comments and assured her the issue would be recorded as one of the Committee’s recommendations.

Ms Windvogel raised several questions regarding the allocation of funds, starting with the R49.5 million being redirected to other projects due to slow progress. She asked what this reallocation meant. How many projects were affected, what were the reasons for the slow progress, and what were the criteria used to determine the funding adjustment?

She asked whether the reallocation of funds to Programme 8: Health Facilities Management was due to challenges that prevented full expenditure this year, such as delays in projects, or if it was a reflection of national government efforts to address load shedding. Lastly, she asked how the additional allocation of R233 million would address service delivery pressures, and what criteria were used to identify which hospitals and facilities would benefit.

Dr Cloete explained that the Department has a schedule of projects for which money was allocated. As the year progresses, usually around October or November, they conducted an analysis to evaluate the speed of expenditure against these projects. The reasons for delays could vary—such as contractors missing milestones, weather interruptions, or other factors. The relevant team could provide specifics on the delayed projects if the Committee required further details.

He clarified that the figures on page 109 related to facilities management reflected shifts between funds. The money had been earmarked for solar panel investment, but because the buildings involved were managed by the infrastructure department, the funds were transferred to that Department to ensure the installation of solar panels in the required locations.

He then addressed the question of the service delivery pressures mentioned on page 109, specifically the allocation of R197 million. He explained that the majority of this funding went into goods and services, particularly for medical and surgical supplies, medicines, and laboratory tests. The service pressures in hospitals like Tygerberg and Groote Schuur had been exacerbated by higher-than-normal inflation, which led to a tight supply window for critical items. This funding would allow the hospitals to maintain adequate stock levels, ensuring they did not risk running out of essential supplies. Additionally, the money would help to replace or repair medical equipment that might break down during operations. The primary goal of this funding was to ensure that hospitals could continue to provide safe and effective medical care, especially in terms of maintaining supplies and functioning equipment.

Ms Windvogel raised a concern regarding the allocation of the funds, specifically asking how the Department identified which hospitals or institutions would benefit from the additional resources. Would the money only be directed to Groote Schuur, or would other hospitals also receive support? She emphasised the need for clarity on which facilities would benefit from the funding, particularly in relation to service delivery. This question aimed to clarify the distribution of the funds and ensure that other hospitals facing similar pressures would also be considered for support, not just Groote Schuur.

Dr Cloete clarified that the funds would not be directed solely to Groote Schuur. The R233 million would be distributed across various programmes. A significant portion, R118 million, would go to central hospitals, including Groote Schuur, Tygerberg, and the Red Cross Children’s Hospital. Additionally, R62 million would be allocated to metro and rural services, primarily benefiting larger hospitals in those areas, as well as planning and care facilities. EMS would receive R15 million, and R12 million would be allocated to regional and psychiatric hospitals. He emphasised that while the distribution of funds would be proportional, the hospitals with the greatest needs for goods and services would receive the largest shares, ensuring the funds are spread across the Department’s various service platforms, from clinics to central hospitals.

The Chairperson asked if there were any further issues to raise regarding the pages of the index. After confirming that no further issues were raised, he reminded members that they were welcome to write to the Department for any additional clarifications at a later time. He confirmed that there were no members of the public present who wished to raise matters. He noted that

Committee Report on Vote 6

The Chairperson recalled two issues arising from the deliberations that called for recommendations. The first was the Department’s comments about the DPSA’s hiring regulations, which were slowing down the filling of vacancies. The second was shifting funds into 2025/26 due to slow progress on infrastructure projects. The Committee should request a detailed report on the projects affected by the slow progress.

Mr Van Wyk supported the vote. He also expressed his appreciation for the Department's efforts, acknowledging the pressures they have faced. He pointed out that the overall funding for the current year reflected a modest increase of 3.5%, which highlighted the tight fiscal constraints under which the Department was operating.

Mr T Walters (DA) also supported the vote.

Ms Windvogel said that in accordance with Rule 90, the ANC minority's position was not to support the budget. She requested that this position be formally recorded. She registered her concerns regarding reallocating R193 million from the provincial equitable share within infrastructure. Additionally, she registered her concern about the reallocation of the budget for COE to fund goods and services. While this approach might address immediate pressures, it undermined the quality of care and service delivery. The most significant impact would likely be felt in poor and working-class communities, where healthcare staff shortages were already a pressing issue. She urged the Department to reconsider this decision and provide assurance that these reallocations would not exacerbate the challenges faced by the health system.

The Chairperson read the report aloud. It read as follows:

"Report of the Standing Committee on Health and Wellness on Vote 6 (Health and Wellness) in the schedule to the Western Cape Adjustment Appropriation Bill (B2/2024) dated 29 November 2024: The Standing Committee on Health and Wellness, having deliberated on Vote 6A (Health and Wellness) in the schedule to the Western Cape Adjustment Appropriation Bill (B2/2024) referred to the Committee in accordance with Standing Rule 188, reports that it supports the vote. We also have a minority view in terms of Standing Rule 90, where the African National Congress (ANC) expressed its minority view to not support the vote.

He said that the report would be submitted to the House. There would be further deliberations in the House at some point next week when all votes have been processed.

The meeting was adjourned.