Western Cape Health Care Challenges: briefing by Health Sciences Faculty at University of Cape Town

HEALTH PORTFOLIO COMMITTEE
4 September 2007
WESTERN CAPE HEALTH CARE CHALLENGES: BRIEFING BY HEALTH SCIENCES FACULTY AT UNIVERSITY OF CAPE TOWN

Chairperson: Mr L Ngculu (ANC)

Documents handed out:
PowerPoint presentation by Prof B Manyosi: Faculty of Health Sciences, University of Cape Town
PowerPoint presentation by Prof D Kahn: Department of Surgery, University of Cape Town

Audio recording of meeting

SUMMARY
The Faculty of Health Sciences at the University of Cape Town briefed the Committee on the major challenges faced by the health services in the Western Cape. Health services were divided into four levels of care but the main challenges centered on the tertiary level of service provided by the associated institutions. An increase in the demand for health care, chronic under-funding and a critical lack of human resources were cited as the main challenges. The briefing included a presentation on the Health 2010 Comprehensive Service Plan adopted by the Department of Health. The policy of strengthening the primary level of care was fully supported. The plan proposed a shift in resources from the tertiary to the secondary and primary levels and further cuts in the budget allocation to the institutions, putting the provision of health care services and the training of health professionals under severe strain. Proposals to address the challenges included planning on the basis of the demand for services instead of from an available budget perspective, providing adequate funding for both training and services and introducing a framework for the governance of Academic Health Complexes by implementing Section 51 of the National Health Act.

Members asked for detailed explanations of the statistics included in the presentation and were concerned over the effects of the budget cuts on the delivery of health care services. Members remarked on the lack of information on the primary level of care, which was excluded from the mandate of the Faculty. Members agreed that further briefings by the Western Cape Provincial Department of Health were required.

MINUTES
The Chairperson introduced the delegates and attendees and said that the briefing touched on some critical issues that influenced the interventions undertaken by the Committee to improve the provision of health care services in the country.

Briefing by Faculty of Health Sciences
Prof Bongani Mayosi (Professor of Medicine) introduced himself and his colleagues from the University of Cape Town (UCT) to the Committee: Prof Gonda Perez (Deputy Dean) and Prof Delawir Kahn (Professor of Surgery). They were later joined by Prof Marian Jacobs (Dean, Faculty of Health).

Prof Manyosi briefed the Committee on the role of the Faculty of Health Sciences, the challenges facing health care in the Western Cape and potential solutions for those challenges (see attached document). He outlined the Faculty’s main objectives and guiding principles and summarised the training and education of health care professionals provided at UCT and the University of Stellenbosch (US). A breakdown of the health care services at the primary, secondary, tertiary and quaternary levels was given.

The three major challenges facing the health care service were increased demand, under-funding and insufficient human resources. Prof Manyosi presented the issues surrounding each challenge and illustrated the trends experienced with graphs and charts. He summarised the impact on tertiary services and on the training of health care professionals. Suggestions to address the challenges included planning on the basis of the demand for services instead of from an available budget perspective, providing adequate funding for both training and services and introducing a framework for the governance of Academic Health Complexes by implementing Section 51 of the National Health Act.

Discussion
The Chairperson thanked Prof Mayosi for the presentation and opened the floor for questions from the Members of the Committee.

Mr B Mashile (ANC) referred to slide 10 of the presentation and asked if the 4% growth in patient numbers at regional hospitals and 8% growth at central hospitals, compared to the overall 6% growth in overall patient numbers was as a result of inadequate funding. He wanted to know if the cuts in the funding of health services in the Western Cape were as a result of the shift in funding to other Provinces.

Ms M Matsemela (ANC) remarked that the presentation was focused mainly on health care at the tertiary and quaternary levels and did not contain much information on the challenges faced at the primary and secondary levels.

Ms C Dudley (ACDP) asked if there were any evidence from the experience in other provinces that increased funding would relieve the problems being experienced in the Western Cape. She asked for an explanation of what was meant by the “framework for governance” mentioned in the presentation.

In response to Mr Mashile’s questions, Prof Mayosi said that the increase in patient numbers was at all levels of care but there was more pressure at the tertiary level, mainly as a result of the increase in acute illnesses resulting from trauma and HIV/AIDS. The 8% increase in patient numbers at the central hospitals did not reflect an inappropriate use of resources or an inappropriate level of care. The health care system in the Western Cape worked reasonably well to ensure that patients are treated at the appropriate facility and at the appropriate level of health care.

Prof Mayosi said that Mr Mashile was correct in saying that there was a shift in resources to poorer areas. He agreed with this policy and supported it but warned against breaking down the rest of the system.

In reply to Ms Matsemela’s question, Prof Mayosi emphasized the interlinked nature of the different levels of care. He said that there was under-funding at all levels and the whole health care system needed strengthening. The Faculty supported the primary and secondary levels and worked and trained at those facilities as well. When serious illnesses were detected at the primary levels they were referred to the tertiary levels for treatment and it must be possible to provide the necessary care at the higher levels as well.

In reply to Ms Dudley’s question, Prof Mayosi explained that the Faculty worked with the Provincial Department of Health (DOH), which budgeted for health care in the Western Cape Province only. However, the Faculty had a national mandate to train, do research and to provide certain quaternary services to the country as a whole. The National Health Act provided for a Ministerial Committee to manage the Academic Health Complexes but this had not been implemented.

The Chairperson asked for a more detailed reply to Ms Dudley’s questions.

Prof Mayosi said that there must be an attempt to match planning to the actual health needs of the population rather than being driven by the available funding. For example, operations were not carried out when there were insufficient funds available and were postponed until the budget became available. He said the Western Cape Provincial DOH had done detailed costing exercises to determine the cost of health care. The management of the Academic Health Complexes was seen to be a national matter in which the Minister played a role that was defined in the National Health Act.

The Chairperson asked whether the DOH at a provincial level could stipulate how many operations were done.

Prof Kahn replied that there were already limitations on some forms of treatment. For example, the number of patients accepted for dialysis was limited to 70 to 80 at any one time, regardless of the circumstances of individual cases. Further restrictions were expected as the Provincial DOH had issued a directive to introduce quotas for all forms of operations.

Prof Perez pointed out that Groote Schuur and Tygerberg Hospitals were national resources and patients were referred to those hospitals from all parts of the country. Funding for these hospitals should not be limited to the amounts provided in the budget of only one province.

Briefing by Department of Surgery, University of Cape Town
Prof Kahn briefed the Committee on the Health Care 2010 Comprehensive Service Plan (CSP) (see attached document). His presentation focused on the impact of the CSP on the delivery of health services, the issues around implementation, the available funding and on the transformation of the health services.

The primary health care approach of the CSP and the principles of providing appropriate care at the appropriate level were fully supported. There was a need to strengthen the primary services (level 1) but most of the impact was on the secondary and tertiary services (levels 2 and 3), such as surgery, obstetrics and gynecology.

Prof Kahn summarised the sub-specialist general surgery services offered by Groote Schuur Hospital and the specialist services offered by the regional GF Jooste, Victoria and Somerset Hospitals and illustrated his presentation with organograms. He explained the common service platform that was established over many years and described the interaction between the four hospitals. The intention of the CSP was to dismantle this structure and to downscale the GF Jooste, Victoria and Somerset Hospitals to district-level services, staffed by non-specialists. The intention was to move the current specialist services to Groote Schuur Hospital. Although Groote Schuur will gain additional beds, there was no provision for extra theatre time. A table of available theatre times illustrated how surgical services had already been reduced and the lack of adequate theatre time was a major concern. A table of hospital beds per province showed a 20% reduction in available beds since 1994.

Prof Kahn said that the lack of theatre time and beds was a crisis as the hospitals were unable to deliver the service required. The CSP proposal to move the specialist services to Groote Schuur Hospital was not an option. The training of health care professionals will also be adversely affected, as registrars cannot be trained at the secondary hospitals. The current structure functioned well – surgery was done at secondary and tertiary levels rather than at the primary level and a negative impact on the training of surgeons was expected.

Prof Kahn reported that, although a 2010 plan, there was pressure from the Western Cape Provincial DOH to implement the CSP. A study of tertiary services conducted by Dr Belinda Jacobs indicated that an average of 40 - 50% of services was at secondary level. At Groote Schuur Hospital, less than 5% of all services were at secondary level yet there was a request from the provincial Department to employ a level 2 surgeon.

Prof Kahn said one of the challenges was the determination of the Director-General of the Western Cape Provincial DOH to introduce a budget-driven health care service. This may be politically correct but will jeopardise health-care delivery in the province. The introduction of quotas was currently being negotiated. The process of transformation was fully supported but the policy of demographic targets in the Western Cape meant that Indian doctors were over-subscribed. Any application from a person of Indian extraction was turned down and Prof Kahn felt that this was unacceptable racial prejudice.

In conclusion, Prof Kahn said that the challenges applied to health care at both the primary and the tertiary levels of care. The request was to retain the current structure and continue to provide level 2 services at the secondary hospitals.

Discussion
The Chairperson thanked Prof Kahn for the presentation and opened the floor to questions from the Members.

Ms M Manana (ANC) stated that discrimination against a particular racial group was not Government policy and the issue needed to be taken up and resolved as a matter of urgency. She asked whether the Faculty was invited to provide input when the CSP was formulated, what the response was and what steps were taken to highlight the issues raised in the presentation.

The Chairperson asked for a more detailed explanation of the situation regarding Indian doctors.

Prof Perez replied that it was the policy of the Western Cape Provincial DOH to follow the provincial demographics of the Western Cape in applying the employment equity policy. Traditionally, there were very few Indians in the Western Cape and preference was given to other racial groups. This issue was raised at a number of occasions. The Faculty believed that the national demographics of the entire country should apply and not just that of the Western Cape.

When asked for his comment, Dr Paul Ciapparelli (Director: Clinical Services, Tygerberg Hospital) said that he was mandated as an observer at the meeting and was unable to comment. He would however record any questions and will ensure that replies were forthcoming.

The Chairperson suggested that the matter be investigated further and that any unsubstantiated speculation was avoided. Further discussion on the subject was deferred.

Mr Mike Waters (DA) referred to a document that was circulated to Members of the Committee only. It was stated that academic hospitals no longer received money from fee-paying patients and that the money will be used by the Department of Health for other projects. He asked for details of these projects, what amounts of money were involved and whether the Faculty was consulted with regard to these projects.

The document referred to an urgent appeal for once-off ad-hoc funding that was made by the Faculty. Mr Waters asked what amount of funding was requested, whether the MEC of the Western Cape Province was approached and what the outcome was.

On the issue of the impact on service delivery as a result of the reduction on funding, Mr Waters asked whether the Faculty had discussed this with the MEC and what was the outcome of the discussions was.

Mr Waters asked if the concerns regarding the CSP were raised with the Department of Health and the MEC and what the reaction was.

Mr Waters asked whether funding was allocated to Groote Schuur and Tygerberg Hospitals to pay doctors for the second year of internship that was required from 2008.

Ms M Madumise (ANC) asked whether patients received any assistance with fees from the Department of Health for treatment at the quaternary level of care. She asked why the budget was being cut for 2010 as an increase in accidents and injuries on the playing fields can be expected.

The Chairperson explained that the 2010 CSP was not necessarily related to the FIFA Soccer World Cup but was the name of the plan given by the Department of Health.

Mr A Madella (ANC) remarked that the presentations were made from the perspectives of UCT and Groote Schuur Hospital but little was said about the challenges faced by other institutions. He referred to slide 11 of Prof Mayosi’s presentation and asked what accounted for the sharp increase in deaths amongst the younger age groups for the period 2004 to 2006. He asked if the trauma units in the GF Jooste, Victoria and Somerset Hospitals were to be closed down as well and wanted to know what the Department’s rationale was for downscaling the hospitals.

Mr Madella referred to the slide in Prof Kahn’s presentation illustrating the 19.8% reduction in the availability of beds. He understood that the beds were transferred to level 1 facilities without a simultaneous transfer of equipment and staff and asked whether this did not represent a net gain for Groote Schuur Hospital.

In response to Mr Waters’ questions, Prof Mayosi replied that the proposed budget cuts called for a shift of R30 million from the central hospital and the closure of 60 beds. Simultaneously, it was decided that the central hospital would no longer be allowed to retain the fees paid by private patients. As there was no longer an incentive to attract private fee-paying patients, the private beds were closed. The matter was extensively discussed with the MEC but the official stand of the Department of Health was that the decision was taken. Prof Mayosi suggested that the question was referred to the Department of Health.

With regard to Mr Waters’ question on the request for ad-hoc funding, Prof Mayosi said that budget cuts were inappropriate in view of the challenges and a way had to be found to acquire additional funds. The request was made to the MEC but there was no indication as yet on the response from the Treasury.

Prof Kahn explained that a small percentage of patients requiring specialist medical care had medical aid. Hospitals were asked to set targets each year for the funds generated in this manner and a percentage of these funds were paid over to the Department. In 2007, a directive was issued from the Western Cape Provincial DOH that hospitals were no longer allowed to retain any fees paid by medical aids and private patients and therefore there was no incentive to attempt to attract fee-paying patients to off-set the shortfall in the budget. As far as he was aware, the bulk of the funds was allocated to the management of level 1 facilities and was not applied to any service delivery projects.

In response to Mr Waters’ question, Prof Kahn said that the Faculty of Health Sciences submitted a comprehensive response to the draft CSP and objections were raised to many of the issues discussed in this meeting. The submission was made to the Director-General, the Minister reviewed it and unilaterally disagreed with each of the issues that were raised, no proper consultation took place before the final version of the CSP was issued and all the proposals made by the Faculty were turned down. Prof Kahn added that the main interaction took place with the Deputy-Director General of the provincial DOH, it was very difficult to gain access to the Director-General, little discussion took place and communication was one-directional.

In response to Ms Madumise’s question, Prof Kahn said that the Faculty also wondered why the budget was being cut when the workload was increasing.

Dr Ciapparelli said that the funding for the training of interns was provided by a national program and was based on the number of interns and where they were allocated to. The first batch of interns required to complete a two-year internship, started in 2007 and he expected that funding would be received in 2008 for the second year of training.

In reply to Ms Madumise’s question, Prof Mayosi said that hospitals applied a sliding scale to the fees payable. In certain cases treatment was free (e.g. mothers and children under the age of 5). Groote Schuur Hospital applied a means test to determine a patient’s ability to pay for the cost of treatment but treatment was never denied on the basis of inability to pay.

In response to Mr Madella’s questions, Prof Mayosi said that Groote Schuur worked closely with colleagues from the Tygerberg and Red Cross Children’s Hospitals and this presentation included information provided by those institutions. He said that the dramatic increase in deaths was attributed to the decline in the health of the population as a result of the HIV/AIDS pandemic, injury and trauma resulting from an increase in violence and an increase in the prevalence of lifestyle diseases such as high blood pressure and diabetes. Slide 9 of his presentation illustrated the 68% increase in the numbers of patients admitted to the Groote Schuur Hospital emergency room over the last four years and was an accurate reflection of the increased workload. The MEC was invited to visit the emergency room and observed the number of patients that were lying on stretchers.

The Chairperson asked if the 68% increase applied to Groote Schuur Hospital only or if it was indicative of a similar trend at the other hospitals.

Prof Mayosi replied that the slide illustrated the increased demand for services at the tertiary level. The emergency room unit at Groote Schuur Hospital admitted patients who required surgical procedures and were referred from other institutions.

Ms Matsemela expressed appreciation for the hard work done by specialists at the tertiary and quaternary levels but reiterated her earlier comment that the presentation did not reflect the primary and secondary levels of health care in the province. She referred to the re-direction of funds to the district health services and asked what was wrong with that. She asked why the training of doctors was in jeopardy when the doctors were being trained to work at the primary and secondary levels as well.

The Chairperson explained that the Faculty of Health Services submitted their point of view and was not mandated to comment on primary health care in the Western Cape. The policy focus was not in question but the concern was raised that one level of health care was enhanced to the detriment of another level. He noted the point that the re-direction of funds was not necessarily a contradiction.

Ms R Mashigo (ANC) asked if the increased numbers of refugees and patients from other provinces were reflected in the budget. She wanted to know if there were adequate infrastructure, human resources, equipment and facilities available to accommodate the shift in services advocated by the CSP. She asked whether Blacks received enough consideration when applying for training as specialists or registrars.

Mr Waters looked forward to a briefing by the Western Cape Provincial DOH on the subject. He asked how many patients were dying because they could not be treated due to insufficient funds. He wanted to know how many were expected to die when the CSP was implemented.

Mr Mashile asked if the cuts in theater times resulted in waiting lists being created. He asked what effect the transfer of level 2 services to district level facilities would have on the hospitals and specialists that previously provided the service. He asked whether the increase in patients at the central hospitals could be attributed to the provision of better services at those hospitals as a result of the allocation of more resources.

Mr Madella asked if there were any cooperative agreements between hospitals with regard to utilising vacant surgery slots. He did not understand why the transfer of services to another facility while the expertise remained at the transferring hospital was regarded as a problem. He asked if any research was done on how patients felt about being the object of study in a teaching hospital. He referred to the comment that there were not enough health care professionals in the country and asked to what extent capacity to deliver more professionals can be increased and what was required to ensure that enough professionals were trained to provide the necessary services.

The Chairperson stated that the rationale for the presentation was for the Committee to be briefed on the challenges faced by the Faculty of Health Sciences and not what the Western Cape Provincial DOH was doing about it. The Committee gathered information from the institutions at the coalface before informing the Province of the challenges that were faced. The total population of the Western Cape, the unemployment rate and the percentage of uninsured people needed to be known. Challenges raised at previous presentations included the recommendation made by the CSIR that Tygerberg Hospital be demolished. It was not the function of a university to train nurses but the closing down of nursing colleges had a detrimental effect on the number of trained nurses. In his State of the Nation address, the President said that the re-opening of nursing colleges had to be accelerated. The Committee had to examine the relationship between the stated ideals of the CSP versus the practice. The budget-driven funding policy was presented as a problem and the question needed to be asked if it was the right policy. With regard to the conditional grants, the Western Cape had the highest per capita allocation of all the provinces yet was still facing challenges related to funding. He reminded the Committee that it passed the National Health Act in 2003 but it was not known to what extent it had been implemented. The role of the Committee included interacting with the Department of Health at both the provincial and national levels to address the issues and to ensure that some qualitative change took place.

In response to the points raised by Ms Matsemela, Prof Perez said that the Faculty was committed to the primary health care approach and the provision of appropriate health care at every level. Students were trained in all levels and underwent training at facilities within the community. She agreed that a shift in resources from the tertiary to the primary levels was necessary and explained that the once-off ad-hoc funding request was required to ensure that the tertiary services were not compromised and the system continued to operate. She explained that students needed practical experience and cannot be trained to perform surgery without performing a number of actual operations on real people. Currently there were not enough operations being performed to train the number of doctors enrolled. The call was to double the number of doctors trained in order to satisfy the needs of the country but a further cut in the number of operations will result in less doctors being trained. It was also important to train doctors to care for their patients and this can only be done by training with real people. Prof Perez said that all levels were important and reliant on the strength of each level. The shift from the tertiary level of care to the secondary and primary levels must however be done in an orderly manner and not at the expense of one or the other.

Prof Jacobs thanked the Committee for the opportunity to meet with it and summarised the salient points of the Faculty of Health Sciences’ presentation. The way the Academic Health Complexes were managed needed attention and there was no clear model of governance. The relationship between the Departments of Health and Education was not formalised and it was hoped that the Committee could assist with that aspect. The Faculty was committed to the promotion of equity across the country, as evidenced by its equitable share of the available funding, the changes made to curricula, the provision of resources to promote equity and the training of students at facilities other than the teaching hospitals. The modernisation of the tertiary services needed to be undertaken and its position within the system identified. Although recognition was given to provide strong primary health care, quaternary services such as transplants needed to be available to all South Africans and the required funding mechanism needed to be in place. The Western Cape experienced pressure on the funds available for health care from the migration of people from poorer provinces as well as the inadequacy of the budget allocation to the Provincial Government. Research showed that an average of 30% of patients screened at the primary level required further treatment at the tertiary level. Black students were only admitted to UCT since the late 1980s and the Faculty pursued an aggressive recruitment campaign at schools in rural and peri-urban areas in an attempt to address the inequalities of the past. Financial aid to Black students and intervention and support programs was introduced. The Faculty was a national educational institution and worked with the Western Cape Provincial Government to implement its mandate to provide health care services.

The Chairperson thanked the delegates from the Faculty for the presentations made to the Committee. He mentioned that a definition of “student” was included in the recent amendments to the Health Professions Act, thus making students subject to the same legislation that governed qualified health care professionals. He said that further discussions on the CSP were necessary and the issue of obtaining funding for the treatment of patients from other provinces had to be addressed. He was concerned by the inaccessibility of officials from the DOH and invited the Faculty to participate in further efforts by the Committee to find the best solutions to the challenges at both the provincial and national levels.

The meeting was adjourned.