Question NW1818 to the Minister of Health

Reply:

The intervention team has submitted a report to the Eastern Cape Department of Health, the Office of the Premier, and the Office of the Minister of Health.

The report submitted covered the analysis and the state of the COVID-19 response in the Eastern Cape for the period, 29th June 2020 until 10th July 2020. The report recommended nine areas of intervention. The recommendation made by the Strategy Team is following the key strategic areas as outlined by the WHO-COVID-19 response guideline as tailored to the provincial needs.

(a) The recommended interventions

1.1 Coordination between Tertiary, Regional and District hospitals is inadequate and should be addressed through the revised command and control structure.

1.2 Given the busy schedule of the SG, it would benefit the Province to have a Project Manager for COVID19 with the necessary authority to fast track actions.

1.3 While the metros have mobilised reasonable infrastructure to meet the surge, the Eastern Cape Department of Health (the Department) needs to give attention to the scaling-up of service delivery requirements such as the adequate provision of oxygen, equipment, human resources, and medicines necessary for the management of the Pandemic.

1.4 Certain hospitals are currently overwhelmed (Doran Nginza in NMB in particular) by the patient demand, and lack of infrastructure, equipment and human resources to meet the clinical care demand which the Department needs to address.

1.5 Labour relations is a matter that requires a dedicated action plan to normalise service delivery.

1.6 Historic arrangements for drainage areas, resource allocation, and referral routing are not addressing the significant surge in patient numbers, particularly in underserved, vulnerable populations.

1.7 Emergency Medical Services and patient transport services require intervention to ensure continued function.

1.8 Within the Province, the oxygen separation plants are located in the Nelson Mandela Bay Metro. The distribution of the oxygen is, therefore, a challenge for areas furthest from the Metro.

1.9 Implementation of a comprehensive data system to capture the parameters of the COVID-19 response.

(b) How far each of the recommendations has been implemented

1. Coordination between Tertiary, Regional and District hospitals is inadequate and should be addressed through the revised command and control structure.

The Intervention Team assisted the Department to establish its Command and Control structure which was adjusted from the Department’s strategic documents.

The structure is divided into three layers, Provincial, district and facility specific. Each structure has adopted an incident management approach (WHO-COVID-19 Guidance) with daily command and control meetings covering the following areas:

• Epidemiology and Surveillance
• Community engagement for prevention, contact tracing and testing
• Laboratory support and result reporting
• Treatment and Care including facility surge capacity
• Infrastructure and equipment
• Logistic support - pharmacy, consumables and personal protective equipment
• Emergency Services
• Psycho-social support to health workers
• Port Health

The strategic area of Port Health is not given a daily focus as Port Health is a national competence. The PMU is vigilant around Port Health issues and receives reports relevant to the Province from the National Department of Health.

2. Given the busy schedule of the SG, it would benefit the Province to have a Project Manager for COVID-19 with the necessary authority to fast track actions.

The Premier of the Province Hon. Mr. Oscar Mabuyane announced the establishment of the Project Management Unit for a comprehensive response to COVID-19. The Project Management Unit(PMU) has established the following structure (Fig. 1 below).

Dr Zungu leads the PMU. She works with Dr Monde Tom, a financial management expert with vast experience in both the public and private sector, leads the Business Continuity Workstream and Mr LauwrenceVanZuydam an experienced HR executive seconded from the Office of the Premier.

The project leader is responsible for directing all COVID-19 activities and for fasting track actions. The PMU has been integrated into the overall Eastern Cape Department of Health’s Covid-19 response and supports the HOD as the accounting officer.

The structure of the PMU and the related workstreams is depicted below.

4. Certain hospitals are currently overwhelmed (Doran Nginza in NMB in particular) by the patient demand, and lack of infrastructure, equipment and human resources to meet the clinical care demand which the Department needs to address.

This recommendation is specific to DorahNginza and Livingstone hospitals as there had been persistent negative media reports about the two facilities.

Dora Nginza Hospital

Maternity Services

The Department resolved the congestion of the maternity wards at DorahNginza by strengthening the peripheral clinics to operate their midwife services. They have also addressed the shortage of staff by fast-tracking the recruitment of doctors and nurses.

Upgrade of Dora Nginza Hospital- 100-bed wing

The Department upgraded a dilapidated wing of the hospital to provide a 100-bed wing to support the COVID19 peak. The project was part of the Province’s “Accelerated Construction Program” which meant that a project that would typically take four months, the constructors completed in two months. The Department handed over the site to DorahNginza Hospital on the 6th July 2020.

Oxygen Reticulation

The National Oxygen Team undertook an audit of the whole oxygen reticulation system of the Dora Nginza hospital. It found that the hospital has four Oxygen Manifolds with only one partially functional. Repairs to the system commenced on the 28th July. The local car manufacturing company has committed to the replacement of two manifolds, and the Department has ordered a further one. The full functionality of all the manifolds will ensure a continuous supply of oxygen at the correct pressure and volume.

Livingstone Hospital

Infrastructure

The Department undertook a project to upgrade the basement to provide an additional 68 Beds with Oxygen. The initiative is also part of the “Accelerated Construction Program”.

Leadership

The Department appointed an Acting CEO for the Livingstone hospital on 22nd July. Also, they have advertised the post of Nursing Service Manager and CEO. The processes will be fast-tracked.

Facilities Management

The hospital management set-up a short-term 6-month cleaning contract. The intention is to ensure that the staff at Livingstone hospital are reoriented into a deep cleaning routine and protocols. The washing machine has been repaired, resulting in improvement with the laundry services.

3. While the metros have mobilised reasonable infrastructure to meet the surge, the Eastern Cape Department of Health (the Department) needs to give attention to the scaling-up of service delivery requirements such as the adequate provision of oxygen, equipment, human resources, and medicines necessary for the management of the Pandemic.

6. Historic arrangements for drainage areas, resource allocation, and referral routing are not addressing the significant surge in patient numbers, particularly in underserved, vulnerable populations.

7. Emergency Medical Services and patient transport services require intervention to ensure continued function.

8. Within the Province, the oxygen separation plants are located in the Nelson Mandela Bay Metro. The distribution of the oxygen is, therefore, a challenge for areas furthest from the Metro.

We have addressed the recommendations 3, 6, 7, and 8 above through adoption of a service delivery model that rearranges the structure and resource distribution within the Eastern Cape health system to optimise service delivery.

Currently, the major urban areas contain all the critical care capacity, that is Nelson Mandela Bay and Buffalo City metros, Mthatha, and to a limited extent, Queenstown. The outer reaches of the western, central and eastern areas are more than three-hour drive time from existing critical care beds. In collaboration with the Provincial Department of Health, the PMU developed a Hub and Spoke approach to address the shortfalls. The purpose of the Hub and Spoke strategy is then to identify the hospital drainage (referral pathway) to existing and or expanded Critical Care capacity coupled with the estimated distance and travel times to reach a bed safely at the peak of the COVID19 Pandemic. The PMU has also determined the high-risk areas based on at least one of the following factors:

• Travel times between facilities
• Travel distance between facilities
• Quality of the road infrastructure
• Quality of hospital infrastructure between the referring hospital and the receiving hospitalCritical care bed saturation

The District team are in the process of confirming satellite hubs for the expanded distribution of COVID19 critical care beds to address the potential shortfall. The PMU will support the Province to optimise existing district hospitals based on minimal input but with a maximum return.

The Department of Health supported by the PMU has made the following progress:

Infrastructure: The following infrastructure projects are underway in the Province, to yield a significant increase in the general ward beds (n=2,022) and critical care beds (n=311). The addition of the infrastructure development from the baseline will address the NEC long-term projected peak demand for COVID-19 admission in the districts and Province. The Rev Dr Elizabeth MamisaChabula Hospital facility will receive an additional upgrade of the current Phase I priority three beds to include additional oxygen supply. The intervention will add 312 oxygen beds to meet the demand in the Nelson Mandela Bay Metro and surrounding districts.

Figure : Estimated General Ward Beds required to meet the demand for COVID-19, current and projects under construction.

Figure : Estimated critical care beds in the Province, and anticipated deficit but can be achieved through the implementation of Hub and Spoke service delivery model.

Equipment: During the reporting period, the PMU identified significant gaps in the availability of a wide range of equipment. Notwithstanding, the team has made substantial inroads into addressing the procurement and distribution of equipment. The following categories of additional equipment have been ordered and delivered according to a schedule that considers shipment and available stock:

• General Ward and ICU patient beds
• Ventilators (procured and USG Donation), CPAP, High-Flow Nasal Cannula Oxygen devices
• Patient monitors, ECG machine, dynamap blood pressure systems
• ICU equipment video laryngoscopes, syringe pumps, suction, oxygen flowmeters

The following table describes the details on procurement:

Emergency Medical Services: Supported by the National Department of the Health, the Provincial Department of Health has acknowledged that the Emergency Medical Services (EMS) and patient transport capabilities for the management of COVID19 are insufficient. The Intervention Team supported the Department in developing a comprehensive plan to strengthen an emergency and inter-facility transportation system to address the hub and spoke referral routing.

The Department has initiated an EMS pilot project which is a Command and Control Centre in the Nelson Mandela Metro. The Department has supported the plan by the appointment of additional EMS practitioners, drivers and patient transport vehicles. The team will now implement similar projects in other districts. The plan includes liaison with the private sector, identifying oxygen refill hubs, and equipping EMS vehicles with ventilation support equipment.

The Province has adopted the Vula Application which is a patient referral system to be used for inter-facility transfers.

Oxygen: A sufficient supply of oxygen is critical for the effective treatment of Covid19 patients. Before an intervention by the National Oxygen Working Group, the Province demonstrated acute shortage of oxygen at the hospital level. Different role-players have mitigated the problem through a range of interventions and contributions. The Province already has completed several oxygen projects essential for the introduction of the expanded critical care bed hub and spoke. Other site developments are still in process.

The prioritised facilities for oxygen upgrades are listed below.

• At Butterworth Hospital, a temporary oxygen tank has been installed while the plinth for the permanent tank is constructed. The installation of temporal tank has been completed.
• At Mthatha Regional Hospital, a temporary oxygen tank has been installed while the plinth for the permanent tank is constructed.
• The construction of the plinths for bulk oxygen supply for the following facilities will follow this sequence:
  1. Sir Henry Elliot Hospital
  2. St Barnabas Hospital
  3. Victoria Hospital
  4. Empilsiweni Hospital
  5. All Saints Hospital
  6. The reticulation Dora Nginza has started this week 28th July 2020 (1 week to complete).
  7. Adelaide next week (03rd August)
  8. Butterworth reticulation to start in two weeks (15th August)
  9. Stutterheim Hospital
  10. Grey Hospital Hospital
  11. MalizoMphehle Hospital
  12. Zithulele Hospital
  13. Holy Cross Hospital
  14. Madzikaneka Zulu Hospital
  15. St Barnabas Hospital
  16. All Saints Hospital
  17. Mpilisweni Hospital
  18. Aliwal North Hospital

The impact of the District Oxygen Supply can be summarised in the table below to demonstrate the increase in the improved oxygen supply.

Labour relations. Labour relations is a matter that requires a dedicated action plan to normalise service delivery

As noted in the report, the resolution of labour issues is key to the successful implementation of the recommendations. Labour relations is employer-employee relationship management with several actions required to resolve the outstanding issues falling into the realm of the Department of Health to resolve. The PMU has raised the issues identified to the DOH and Premier. In response, the Premier has seconded Mr Lawrence Van Zuydam to lead the effort to resolve these. The Minister of Health has met with the provincial leadership of the Trade Unions in Health in the Province, and the Member of Executive Council holding the ongoing engagement.

The PMU has provided a detailed analysis of the human resource requirements as assessed by the National Department of Health according to the Anaplan, aligned with the National Epidemiology Consortium long-term projection. The Provincial Department of Health is addressing the human resource requirements through the implementation of rapid recruitment strategies.

Implementation of a comprehensive data system to capture the parameters of the COVID-19 response.

Key to the interventions is the data collected in the NIDS, Dat.COV, Vula systems and comprehensively collated to ensure the number of beds available at the facility and per the strategic planning. As the epidemic evolves, the monitoring evaluation data is required daily to ensure that PMU is responding to the changing situation. The PMU is placing special attention of the data requirements for contact tracing, quarantine, isolation, hospitalisation and deaths.

The progress has focused on a review of the data collection capacity, human resources, connectivity and routine data reporting from each facility. An increase in the number of facilities routinely reporting data has been achieved. The M&E team will integrate the routine clinical data with the laboratory testing data, and mortality data to provide a comprehensive overview of the pandemic progress in the Province.

END.