Hospital Revitalisation Programme and Retention of Health Professionals: Department briefings

Meeting report

SOCIAL SERVICES SELECT COMMITTEE
24 August 2005
HOSPITAL REVITALISATION PROGRAMME AND RETENTION OF HEALTH PROFESSIONALS: DEPARTMENT BRIEFINGS

Chairperson: Ms M Madumise (ANC)

Documents handed out:
Department PowerPoint presentation on Hospital Revitalisation Programme
Department PowerPoint presentation on Recruitment and Retention of Health Professionals

SUMMARY
The Committee heard a Health Department presentation on the Hospital Revitalisation Programme (HRP) that covered the Department’s vision and the Hospital Revitalisation Grant. Officials further explained the process and methodology followed by the Programme, and their challenges and achievements.

Members’ concerns centred mostly on the problems caused by difficulties with the Department of Public Works and the shortage of HRP projects in some provinces. Questions were also raised around the role of Hospital Boards and the size and design of hospitals. They suggested that empowered partnerships between big and small contractors might provide a solution to the completion delays.

The Department’s Human Resources team then presented their progress and challenges in the task of recruitment and retention of health professionals. A Strategic Framework for a HR Plan had been launched. A unified training programme was being developed for Community Health Workers (CHWs) and the cadre was being regulated.

The Committee raised concerns and suggestions about migration of nurses overseas; the need to introduce community service for nurses; the need to train more nurses and alleviate the serious skill shortage, the problem of unaccredited colleges providing pre-nursing training and the shortage of social workers in hospitals.

MINUTES

Department briefing on Hospital Revitalisation Programme
The Department 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 based on 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.

Discussion
Mr M Sulliman (ANC) asked if the Eastern Cape had a problem submitting plans as their allocation of funds for 2006/07 in the Medium-term Expenditure Framework (MTEF) was so low. Dr Sibeko responded that provinces were not given funds unless they had submitted business cases. Mr Steyn indicated that provinces did receive the amounts requested. The funding was project based and the Department encouraged provinces to submit better business cases for more projects. The Chairperson enquired whether the Department advised and assisted provinces to improve their business cases. Dr Sibeko explained that the Department provided provinces with funding to engage consultants to assist in the process. Mr Steyn added that the Department appraised the business cases and any queries were discussed with provinces. The national office provided provinces with extensive expert assistance. While the first business cases developed had proved challenging, provinces were now becoming more proficient. He reiterated that the development of business cases was the most important area for determining health facilities and health care for the provinces. Ms H Lamoela (DA) expressed concern over the backlogs in HRP in the poor areas of the Eastern Cape.

Mr Sulliman referred to the ‘Reasons for Delaying Transfer’ chart and asked if the National Department would be assisting provinces in carrying out the necessary tasks. Mr Steyn responded that transfers had been deliberately delayed, as provinces had not met with the DoRA conditions.

Mr B Tolo (ANC) asked who designed the hospitals noting that some were beautiful and others not. Mr Steyn responded that it differed between provinces. Most provinces used outside architects though the Western Cape had an expert in hospital design. The Department agreed that a standard for design needed to be set.

Mr Tolo noted that the Department of Public Works had caused construction delays for many Departments. HRP should be using their own experts ‘on the ground’ to monitor the situation and meet with PWD on site, rather than relying completely on the PWD. Dr Sibeko responded that the problem was political. While it might seem obvious to use other parastatals as implementing agents, there was pressure to use PWD and maintain its power base.

Mr Tolo felt that provinces seemed to be waiting a long time for the allocation of funds and should plan further ahead, so that building could commence as soon as funds were allocated. Mr Steyn explained that design and location planning could start when the business cases were submitted.

Mr Tolo suggested pairing big and small businesses to increase efficiency and productivity. Mr Steyn agreed that the development of empowered pairing was an excellent suggestion. He was meeting with a top financial analyst to discuss ways of involving big business in the revitalisation process.

Mr M Thetjeng (DA) asked what determined the size of hospitals and number of beds. Mr Steyn replied that the size of the population in the area was looked at, the number of uninsured people and whether the area was covered by any other hospital facilities. There was a standard admission rate depending on whether the facility was a level one, two or three hospital. A mathematical equation existed to determine number of beds, based on 80%% occupancy at all times. Large hospitals with occupancy of only 30 – 40% were not cost-effective. He stressed the need to build the right facilities of the right size in the right place with the right care at the right cost.

During oversight visits, Mr Thetjeng cited examples of cattle scavenging in medical waste sites and streams being polluted and asked if proper medical waste sites were being planned for the new hospitals. Dr Sibeko agreed to investigate the situation, but added that the hospitals were designed for efficiency and should include a medical waste disposal plan.

Mr Thetjeng asked if it would not be more efficient to refurbish old hospitals. Dr Sibeko responded that if the cost of refurbishing an old hospital was greater than 60% of its value, then building a new one was more cost effective. New hospitals were also designed differently, with smaller wards and shorter passages. In addition, hospitals built during the apartheid era were often incorrectly situated for easy community access.

Ms Lamoela asked why contracts were awarded to small contractors who were unable to do the job properly. Mr Steyn explained that the Department unfortunately had no control in the awarding of contracts.

The Chairperson asked for an update on the state of the Pretoria Academic Hospital, which had been viewed as a ‘white elephant’ in the past. Dr Sibeko responded that the hospital had not budgeted for equipment. The Department would write a detailed response on this case and submit it to the Committee.

Ms J Vilakazi (IFP) expressed concern about the poor condition of hospitals in KwaZulu-Natal. Mr Steyn noted that the KwaZulu-Natal situation had improved enormously, and the province had the most projects currently on site. The new level one hospital on the King George Hospital site was under construction.

Mr J Thlagale (UCDP) noted that in poor rural areas, communities insisted on using local contractors and workers who often did not have the necessary skills. He suggested the Department intervene in such situations to prevent funds being wasted. Dr Sibeko cited the successful revitalised Colesburg Hospital where a group of large contractors sub-contracted locally.

Ms N Madlala-Magubane (ANC) felt that ‘toothless’ Hospital Boards needed to be trained by the Department to improve service delivery. Dr Sibeko noted that legislation was being developed outlining the roles and responsibilities of Hospital Boards, which would transfer power from the centre to communities.

Dr Sibeko suggested that Members were welcome to contact the Department for photographic details of HRP projects in specific provinces.

Department Human Resources briefing
The presenters were Ms G Gumede (Chief Director Human Resources Planning, Management and Development) and Mr A Crichton (Director Strategic Planning). One of the major challenges facing the recruitment and retention of health professionals had been the increasing global phenomenon of migration. Young people travelled overseas in search of wealth and international exposure. South Africans were regarded as skilled and competent workers. The Department had engaged with governments overseas to encourage the repatriation of professionals. Within South Africa, rural young people were increasingly choosing to move to the urban areas.

Remuneration packages for health professionals needed to be improved. The HRP would create improved working environments. The information system needed improvement. The National Health Council (NHC) had made a decision to reopen nursing colleges to avert the nursing shortage crisis. Educational institutions needed to be strengthened to improve skills development. Academics needed to be properly valued as many had left the education field over the past number of years.

A unified training programme for Community Health Workers (CHW) was in development and regulation of this cadre was being investigated. There were challenges of stipend variances, blurred scopes of practice and lack of co-ordination of CHWs. The mushrooming of non-accredited training providers presented an enormous problem. The Department had been working with the South African Nursing Council to sort out those challenges. The comprehensive training of CHWs enabled a ‘one knock approach’ being utilised at a home community level.

The Minister launched the Strategic Framework for the Human Resources (HR) Plan. Stakeholder briefings had been held and the input deadline was 15 September.

Discussion
Ms P Mazibuko (ANC) raised concerns about the ability to retain personnel deployed to rural areas. The CHW was viewed by the unemployed as a way to make money before moving on to ‘greener pastures’. Ms Gumede responded that some student bursaries ensured the recipient would return and serve in the rural area. The government policy of ‘serving government’ after graduating needed to be more specific about the areas to be served.

Ms Mazibuko noted that the CHW programme targeted younger people, when many patients preferred care from older health workers. Ms Gumede agreed that many black people did prefer treatment from a mature dignified CHW. However, many young CHWs were caring and all were trained to provide quality service.

Ms Mazibuko asked if stipend variances in different areas were going to be regulated. Mr Crichton responded that the CHW Policy Framework was linked to the Stipend Policy Framework and there were three categories of stipends.

Ms Mazibuko raised the issue of learners who were unable to be admitted to nursing colleges due to poor grades. The ‘fly by night’ colleges fraudulently promised them pre-nursing courses which would ensure them admission to nursing college. Mr Tolo agreed that with so many young people wanting to study nursing, the Department should assist with providing proper training. Ms Gumede noted that the unaccredited colleges were being closed down. Mr Crichton cited examples in KwaZulu-Natal and the Western Cape where learners were identified before Grade 12, assisted to achieve better grades and drawn into the bursary system. Ms Gumede noted that the HR Plan sought to engage producers of health professionals. The capacity of institutions needed to be assessed and discussions with the private sector would possibly lead to a pooling of educational resources to benefit the whole national system, both public and private.

Ms Mazibuko raised the need for nursing colleges to measure performance, as there were cases of student nurses failing repeatedly, but continuing to receive subsidies and remain in college. Stricter performance measures were needed on the one hand, and yet greater enrolment was needed on the other. Mr Crichton explained that student nurses were given working posts while training and so had employee rights and privileges. It was difficult to remove those failing from the system. Ms Gumede added that a certain amount of flexibility to fail was provided, but students could not spend ten years in a four-year course.

Mr Thetjeng asked why nursing colleges had been closed down when there was such a shortage of nurses, only to be reopened again later. Ms Gumede explained that rationalisation had occurred due to overlapping and money being wasted. However, the colleges were now offering different specialities. Many nurse educators had moved into management, private facilities or immigrated. It was necessary to develop a plan to bring them back as the colleges were reopened.

Mr Thetjeng suggested that the scarce skills allowance be made available to people willing to work in rural areas as an incentive, but that the allowance was cut once they left.

Mr Tolo suggested a more concerted campaign to encourage nurses to stay in South Africa. Training was costly for South Africa and the wealthier United Kingdom was benefiting at our expense. A patriotic approach needed to be developed. He suggested the introduction of community service for nurses. Ms Gumede responded that the Bill was before Parliament and needed to be passed before community service could be enforced. Some urban medical schools were not transformed enough to encourage patriotism. Graduates from universities such as Medunsa were more likely to stay and work in rural area. Migration was a reality and extra capacity needed to be developed to allow for people leaving. Ms Mazibuko noted that health workers were often recruited by agencies for overseas programmes and ended up working menial jobs in bad conditions beneath their level of qualification. The Department needed to address this issue seriously.

Ms Mazibuko asked if South Africa received nurses in the exchange programmes or only sent them overseas. Ms Gumede acknowledged that South Africa did have agreements with Saudi Arabia and the UK to send nurses. South Africa did benefit from the exchange by receiving specialists who provided service and skill transfer at hospitals.

The Chairperson asked about the HR budget spent on personnel. Mr Crichton clarified that the Department had under spent by only 1.6%. This represented 4 000 vacancies out of a total of 10 000-funded posts for health workers. Ms Mazibuko asked HR to provide the Committee with a written list of the supposed number of health professionals for each hospital and a list of the numbers currently employed. This would help in oversight visits.

Mr Thetjeng asked what the HR perspective on the shortage of social workers in hospitals was. Mr Crichton responded that the problem was one of completion rather than training. There were cases where students were unable to pay class fees and so were not allowed to graduate. In addition, social workers had to practice for one year before registering, and there were not enough opportunities to do so. Dr Sibeko added that the shortage of social workers continued to be a challenge as they played a crucial role in assisting patients to leave hospitals more quickly.

The meeting was adjourned.