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HEALTH PORTFOLIO COMMITTEE
31 May 2005
HOSPITAL REVITALISATION PROGRAMME: DEPARMENT BRIEFING
Chairperson: Ms M Madumise (ANC)
Documents handed out:
Department PowerPoint presentation on National Human Resources Health Plan
The Committee heard a presentation on the Hospital Revitalisation Programme that covered the Department’s vision and the Hospital Revitalisation Grant. It further explained the process and methodology followed by the Programme, and the challenges and achievements.
Members’ concerns centred mostly on the division of responsibility between the national and provincial Departments of Health, the capacity of the provinces to execute the projects and problems caused by difficulties with the Department of Public Works. Questions were also raised around the identification and prioritisation of projects, projects costs and completion deadlines.
Hospital Revitalisation Programme Presentation
The presenters were Dr Thabo Sibeko (Chief Director: Hospital Services) and Mr Gert Steyn (Director: Hospital Revitalisation). The Programme was funded by a conditional grant as legislated for under the Division of Revenue Act. It included the implementation and monitoring of quality improvement programmes to comply with Government’s Batho Pele campaign. Furthermore, sustainable planned preventative maintenance and replacement programmes supported by appropriately qualified and trained staff and technical resources were necessary to ensure the non-reversal of the achievements of any particular project within two to three years.
The Programme envisaged the revitalisation of thirty hospitals over an initial fifteen to twenty year period, followed by the remainder of the country’s 405 hospitals. According to the Programme’s division of responsibilities, the identification of new projects depended on the submission of business cases by the Provincial Departments of Health to the National Health Department. These prioritised new projects on the basis of service delivery issues (including political risk) and the provision of a value for money figure.
The presentation identified three major challenges to the Programme. These included various problems relating to the ability of the Department of Public Works to complete projects within expected time frames; problems around the capacity of the Provinces to execute the revitalisation projects; and, the inefficiency of communication between the provinces and the National Department. Achievements of the Programme included the completion of two hospitals in the Northern Cape and one each in North West and Mpumalanga.
Mr I Cachalia (ANC) observed that there were still many problems with the Hospital Revitalisation Programme (HRP) despite the fact that it was launched in 2003 already. He required further clarification on the problems experienced with tender procedures and the management of projects. He asked whether Public Works should be engaged on these matters, and in relation to the underspending of grants by the Provincial Health Departments.
Ms R Mashigo (ANC) also noted that Public Works had been identified as the culprit in the delay of a number of HRP projects and asked whether there was sufficient dialogue between the two departments.
Dr Sibeko explained that the Department attempted discussions with Public Works. The national Department of Public Works maintained that they had no authority over provincial Public Works Departments. This created a problem in that it was the provincial Departments that saw to the execution of infrastructure provision for HRP projects. Government-wide, Public Works was deemed a problem department.
Mr Cachalia raised issues regarding changes in the completion dates of some of the HRP projects, and asked whether population shifts due to migration had been taken into account in the business cases submitted by the provinces.
Dr Sibeko responded that more regular, but shorter briefings than the annual presentation should be given to the Committee by his Department in order to deal with issues such as changes in the expected completion dates of the HRP projects. While population projections were integrated into the business cases required for the identification and prioritisation of new HRP projects, it remained a challenge for service delivery because of increasing urbanisation.
Mr Steyn elaborated that these projections extended ten years into the future, but that the exponential increase of urbanisation and the effect of AIDS in the rural areas remained a challenge to the current model that would have to be dealt with. Various types of statistics such as population density, unemployment- and income levels were taken into account in deciding the location, -size and -shape of hospitals.
Ms D Kohler-Barnard (DA) observed that Dr Sibeko mentioned that people would be brought in to see that the Department are not ‘cheated’ in the building of hospitals. She wanted to know whether he was referring to Public Works or to private contractors. During the budget hearings of KwaZulu-Natal, Professor G. Thompson said that they had ‘fired’ Public Works because the services they had rendered were appalling, and that the experience in that province was that contracting private companies provided the only sure route for the timeous completion of projects. Secondly, she required further clarification on the co-operation between the accounting officers present and their directorates and, the ‘powers that be’ with regards to the human resources strategies that were to be employed in the staffing of the revitalised hospitals.
Dr Sibeko replied that he was referring to the double standards applied by the private sector when rendering services to the Department of Health in the construction of infrastructure, in comparison with the service given to private health service providers. He motivated that the standards should be the same across the board. The directorate was working closely with Human Resources in the Department of Health in order to plan successfully for the staffing of the revitalised hospitals. A main objective of the strategy was to attract the interest of potential staff while they were still studying.
Ms R Mashigo (ANC) referred to the project management unit alluded to by Mr Steyn during the presentation, and enquired whether it was funded, operational and ready to provide date-line implementation plans. She then questioned the efficiency of the project management structure discussed by Dr Sibeko in the beginning of the presentation.
Dr Sibeko responded that the project management unit was funded, but that staff appointments proved time-consuming. The Department would make written date-line implementation plans available to the Committee. Implementation of the project management structure was also protracted and not functioning optimally. Perhaps the cause was the novelty of the HRP and the thinking behind it. He encouraged the Members to be strict on this in their oversight as they visited some of the HRP project sites, as the National Department was experiencing problems in getting co-operation from the provinces in this regard.
Dr R Rabinowitz (IFP) felt that the conditional grants system was not working and that the causes for this should be found. A lack of clarity in the division of accounting- and management responsibilities for these projects was to blame and a change in the structuring of programmes such as the HRP was in necessary.
Dr Sibeko replied that the conditional grants system was useful as it was conditioned on strict awarding criteria and because it specifically regulated how the funds would be spent. It also made for clarity in the division of the responsibilities between the provincial and national departments (slides six and seven of the presentation).
She further noted that if the Provinces were to execute these projects, they were supposed to do so through the district system. The district health system was supposed to be operational, IT-systems were supposed to be in place and movements and needs were supposed to be accurately tracked. As that has not happened, the information that the execution of HRP projects was based on was ‘ill-defined and vacuous’.
Dr Sibeko responded that concerns around health IT-systems could not be best responded to by his directorate and suggested that the relevant officers be called in to account to the Committee on the issue. Quality information was necessary for the completion of the business cases by the provinces. He affirmed that his directorate invested much effort in the monitoring and evaluation of this information.
Dr Rabinowitz recalled the devolution of Public Works powers to the provinces because of the inefficiency of the national Department. She expressed her concern at the ‘to-ing and fro-ing’ between the national and provincial departments of Public Works. This created space for the non-procedural awarding of tenders to preferred parties where large sums of money were at stake. This might also be the reason for the sub-standard work being delivered to the public sector in infrastructure construction.
Overall, Dr Rabinowitz lamented the lack of public private partnerships (PPPs) in the execution of projects such as those executed under the HRP and observed that Dr Sibeko had worked on PPPs in the past.
Dr Sibeko recounted the adage that the government should not ‘PPP away’ their problems. Where this was appropriate, it was done. An example was in rural areas, where co-operation with private General Practitioners saw them enabled and encouraged to admit their patients and work in revitalised public hospitals.
Ms B Ngcobo (ANC) enquired whether the revitalised hospitals would be able to deliver client-focussed, ‘super-market’ type care. She further probed the issue of hospital boards: whether they were trained and whether they understood exactly what they were accountable for.
Dr Sibeko replied that the outputs expected from the provinces per site were clearly indicated in the project implementation plan (PIP). These encompassed the issue of community involvement in health, and as sub-outputs to that, the appointment and training of hospital boards. The hospital management and quality grant contained the necessary funds for this to be executed, but the Department remained strict on the disbursement of these funds as lack of achievement in this area was central to the problems of the HRP projects.
Ms M Madumise (ANC) noted the provision that community structures were to hold revitalised hospitals accountable. She enquired whether these structures were in place and whether they were doing what they were supposed to do. She also questioned the disparity in the cost per bed ratio between the various hospitals that were completed, or were scheduled to be completed in the near future. Finally, she asked whether the revitalised hospitals might be described as "state-of-the-art" as it was promised with the commencement of the HRP.
Dr Sibeko agreed that the critical community structures were vital in holding hospitals and hospital boards accountable, but lamented, that unlike in the United Kingdom, the real importance of such a dynamic was not yet realised in South Africa. He further expressed his dismay that these structures were often populated by affluent individuals who did not make use of public healthcare themselves. More elaborate assessments were necessary before a proper answer could be delivered.
Mr Steyn explained that the disparity in the cost per bed ratio between the different hospitals was due to the differences in the provisions for staff accommodation.
Dr Sibeko expressed his confidence in the standard put there by the revitalised hospitals and in their ability to compete with private facilities. He encouraged members to visit completed HRP projects themselves.
Mr Steyn elaborated that state-of-the-art equipment was supplied without question where the need for it was certain and where it contributed to reduced operational costs and increased efficiency. The challenge was for provinces to align their thinking to this approach. Also, because of increased experience, planning and project intelligence, new and revitalised facilities were increasingly achieving world-class standard to a greater degree.
Mr Cachalia asked whether the national Department of Health had put any mechanisms in place to continuously monitor the progress of the provinces in the execution of HRP projects. He required further clarity on the national project management strategy of the HRP. Mr Cachalia also noted that in 2003/04 the purchase of equipment was a major problem in the provinces as there was a delay in the reinstatement of the national tendering procedures. He asked whether any progress had been made in this regard, and whether it had affected HRP projects negatively.
Mr Steyn explained that the monitoring mechanism was in place in the form of a project management unit, but its staffing was yet to be finalised. The outputs for this unit were also known as they were laid out in the PIP. The unit’s budget for 2004/05 was R872 000. This increased to R5.1 million for 2005/06. The staffing plan will see project specialists (organisational development and quality improvement; infrastructure; health technology; and, monitoring and evaluation) on site in the various provinces 150 out of the 211 possible working days of the year.
Mr Steyn added that in the past there was greater focus on infrastructure development and little attention paid to organisational development, quality improvement and health technology. Also, these different focus areas were not managed concurrently, but sequentially. The approach had changed in this regard and it was communicated to the provinces. Currently audits for health technology were conducted during the design and planning phase of new hospitals. He mentioned the example of Vredenburg Hospital, where the equipment was procured during the construction phase and was already stored on-site. Thus, the moment a ward opened, the equipment could be rolled out.
Ms Madumise asked whether the equipment was of South African origin or imported.
Mr Steyn responded that some of the more specialised equipment was imported from global specialist manufacturers such as Siemens-Phillips, because of their research and product development capacity and the economies of scale that these products required to make them affordable to manufacture and sell. Smaller and less specialised equipment could, and were, procured from South African suppliers.
Dr Rabinowitz questioned the construction cost per bed of a million rand per bed and more with some of the smaller hospitals. She asked whether there was a comparative index which could be appealed to in this regard. She also asked whether there was a minimum standard for the construction and equipment of every hospital. She then probed the roll-out of tele-medicine, and whether security made out part of the planning for revitalised hospitals. Finally, she asked whether there was still legislation governing the regulation of medical devices.
Mr Steyn explained that there were cost indicators for the construction of hospitals. It was however, important to remember that there were certain fixed costs involved, irrespective of the size of the hospitals, and that these tended to make smaller hospitals more expensive to construct in terms of a cost per bed ratio. In addition, the costs for the construction of some of the smaller, rural hospitals included the construction of staff accommodation. As the HRP progressed, data was also being collected to ensure the proper monitoring of current and future projects.
Dr Sibeko responded that the use of tele-medicine was expanding, and that the relevant officials would be notified to prepare a written report for the Committee on the matter. The regulation of medical devices, on the other hand, fell outside the jurisdiction of the Directorate of Hospital Services.
Mr Steyn described the issue of security as a central concern of the planning and execution of HRP projects.
Ms Ngcobo asked whether there was an initiative to train local technicians to maintain and manufacture some of the equipment that was being purchased as a way in which to contain costs.
Mr Sibeko explained that if equipment purchases were made from international suppliers in significant quantities, the Department was keen to exercise its bargaining power to motivate these suppliers to establish a local presence to aid job creation. The purchase of health technology equipment was made in accordance with the Department’s ‘ten-point procurement plan’. The political will existed for the country to develop its health technology industry
Ms Mashigo queried whether the business cases could be influenced by the communities who would be affected by their outcome.
Mr Sibeko replied that it was the prerogative of the provincial office to ensure that the opinions of the communities were considered in their prioritisation of the business cases.
The meeting was adjourned.