Report of the Portfolio Committee on Health on oversight visit to Mpumalanga Province from the 16 to 17 September 2013, dated 12 March 2014

The Portfolio Committee on Health (the Committee) having undertaken an oversight visit to Mpumalanga Province from 16 - 17 September 2013 reports as follows:

1. Objectives

One of the functions of the Portfolio Committee on Health is to conduct oversight. The Committee therefore conducted its oversight visit in Mpumalanga Province from the 16 to 17 September 2013. The purpose of the visit was to assess infection control strategies and the quality of health services, the referral system and the functioning of the primary health care system, roll out of ARVs and drug stock outs, achievements and challenges with the roll out of the National Health Insurance Pilot Project. The Committee also wanted to gain insight into the functioning and recruitment of retired nurses, how they are compensated and their scope of work. The Committee also wanted to assess revitalisation projects and their functionality as well get a report on the deaths of initiates.

2. Delegation

The delegation comprised of the following Members of Parliament:

Dr MB Goqwana (ANC and the Chairperson of the Committee); Ms TE Kenye (ANC); Ms BT Ngcobo (ANC); Ms SP Kopane (DA); and Ms H Msweli (IFP).

The following officials accompanied the delegation:

Ms Vuyokazi Majalamba (Committee Secretary); Ms Nombali Magubane (Committee Assistant); Mr Moses Mncwabe (Committee Researcher); and Ms Lindokuhle Ngomane (Content Advisor) .

3. The Committee visited the following public health facilities:

KwaMhlanga Hospital, Verena Community Health Centre and Ermelo Hospital.

4. OVERSIGHT AT KWAMHLANGA HOSPITAL

On the 16 September 2013, the Committee conducted its oversight at KwaMhlanga Hospital. The Committee met the following delegation at the hospital:

Ms Nokwanda Phokoje (Acting Chief Executive Officer (CEO); Dr G Thwala Nkangala (District Coordinator); Ms TB Nkosi (Assistant Director); Mr VW Mndebele (Pharmacy Supervisor); Ms LB Lukhele (Operational Manager); Mrs NN Masilela (Assistant Director); Ms MM Mabena (Quality Assurance); Mr JK Rammutla (Delegated IPC); Ms ET Masemola (Secretary to the CEO); Ms PT Tause (Emergency Services Coordinator); and Mr JM Thamasa (SSA).

Ms Phokoje briefed the Committee and gave a background of the district municipality. She informed the Committee that Thembisile Hani Local Municipality is located in the Nkangala District Municipality of Mpumalanga Province and is a semi-urban Local Municipality. The geographical area of the municipality is approximately 2493.49 square kilometres. The municipality forms part of a larger economic sub-region of Tshwane and Johannesburg and that the municipal offices and chambers are located in Kwaggafontein.

She also noted that the majority of the people in Thembisile Hani Local Municipality are still very young according to the population data and are aged between 0 and 24 years old. The percentage of pensioners in Thembisile Hani Local Municipality is 4.8% as compared to 4.4% of the province and 4% in Gauteng Province. Ms Phokoje also noted that the level of education in Thembisile Hani Local Municipality was low which indirectly affected the health and life expectancy.

The Acting CEO informed the Committee that Kwa-Mhlanga hospital was classified as a District level one hospital and provides comprehensive care on a 24 hour basis. It provides inpatient care for treatment of common diseases, injuries and normal deliveries. It is a non-specialty facility to which patients from the surrounding clinics are referred. The hospital is in a rural area and its nearest provincial referral hospital is Witbank Hospital which is 112 km away from Kwa-Mhlanga Hospital.

Services that are provided at the hospital are as follows: general wards, maternity ward, paediatric ward, 72 hour mental health services, victim empowerment room, theatre, 24 hour casualty department, general outpatients for patients referred from the clinics and self referrals and wellness clinic. Services offered under allied health services are speech and audiology, social worker, radiographic, physiotherapy, occupational and clinical psychology services. The clinical health services that are offered at the hospital are dental, medical and pharmaceutical services.

Other services that provided by the hospital under support services includes; laundry, CSSD, food, housekeeping, maintenance, security services, labour relations, human resource, finance, procurement and provisioning, asset management, transport and hospital information.

Health services in the Primary Health Care are provided through the following facilities: 20 primary health facilities which 14 are eight hour clinics and six are twenty four hours community health centres. There are also four mobile clinics that are servicing 17 points.

The inpatient bed utilisation rate was at 58% in April, 66% in May, and 68% in June. The caesarean section rate was above 10% in April, at 20% in May and above 15% in June.

On quality assurance the Acting CEO highlighted that the hospital has a dedicated professional nurse doing quality management and another professional nurse dedicated for infection prevention and control. The hospital has also developed quality improvement plans with special focus on fast tracking the ministerial six priorities. A client satisfactory and patient time surveys have been conducted. The institution was also reinforcing hand washing to break the chain of infection and cross infection. The hospital was also planning to improve management of waste on medical, domestic and pharmaceutical. The institution was also planning on intensifying surveillance of communicable diseases and notification and monitoring of compliance to policies and QIPs. On quality assurance the hospital was improving the management of dirty linen with more focus on proper handling and dispatch.

Ms Phokoje noted that drug stock availability stands at 86% due to revised drug list and that ARV roll out was an ongoing process and the total number of patients already on ART stood at 28836 apart from the patients that remained on ART newly initiated for the current financial year was 1056 for Kwa-Mhlanga Hospital.

On referral system the Acting CEO noted that the health system within the Mpumalanga Province began at the Primary Health Care level where the referral system begins. Patients within the community start at a local clinic as the first point of entry and if the need of a patient surpasses what the clinic can offer, they are then referred to a district hospital. The next level of referral from a district is a tertiary hospital. Witbank does not have a full package for a tertiary hospital and it is for that reason that the province is having a Memorandum of Agreement with the Gauteng Provincial Department of Health for services that cannot be provided such as oncology, urology and neuro-surgical services.

The vacancy rate for management and support staff is at 67% with 42% for dentists, 34% for professional nurses, 75% for nursing assistants, 100% for pupil nurses, 68% for pharmacists, 27% for radiographers, 78% for physiotherapists, 63% for occupational therapist, 20% for pharmacy assistants, 25% for dental assistants, 50% for occupational therapist assistants, 50% for speech therapists, 54% for finance, 100% for audiologists, 100% for oral hygienists, 100% for dental therapists, 83% for darkroom attendance, 67% for medical social worker , 0% for groundsman, 63% for corporate services and 41% for cleaners.

4.1 Budget

The total budget for Kwa-Mhlanga Hospital for the current financial was R130, 789,000 million. The bulk of the budget (R110 million) is allocated to compensation of employees, with R19million has been allocated for goods and services. Six thousand has been allocated for provincial and local government. Forty seven thousand has been allocated to transfers and households while R917, 000 has been allocated to capital. The hospital has overspent by 194% on provincial and local governments and 498% for transfers and households.

The overall maintenance budget for 2013/13 is at R300, 000. The infrastructure maintenance budget was R150, 000 and the expenditure including commitments was at R2, 690. The maintenance of medical equipment budget allocation for 2013/14 was R150, 000 and the expenditure including commitments was at R30, 742.

4.2 Infrastructure

On infrastructure, the Acting CEO highlighted that progress made on revitalisation of the ICU was at 99%, the old theatre not yet started, new OPD at 98%, old OPD and admission at 76%, public toilets were completed while the new gas plant room was at 75%.The borehole was finished but cannot pump water.

4.3 The following were challenges facing KwaMhlanga Hospital:

· The mortuary, laundry, kitchen, pharmacy and maternity ward are too small and the medical waste storage area was also too small.

· The fence for the hospital has dilapidated.

· There is insufficient accommodation for all health professionals which makes it difficult to attract and retain staff.

5. OVERSIGHT AT VERENA COMMUNITY HEALTH CENTRE

The Committee met with the following delegation at the health centre:

Mrs Cheryl Nelson (Primary Health Care Director); Ms E Monapa (Operational Manager); Ms TB Nkosi (Assistant Director for Primary Health Care); and Mrs LN Fakude (Assistant Director HAS).

Mrs Nelson briefed the Committee in Verena CHC which was established as a mobile point in 1997 with one professional nurse and an assistant nurse. The services that were rendered in the container were donated by Astra Zeneca. The current structure was erected and started to operate as an eight hour service in 2000 and in 2002 began to operate as a 24 hour facility. The facility is situated 50 kilometres away from Bronkhortspruit and 45 kilometres from Kwa-Mhlanga Hospital. The CHC serves all the sections of Verena community including Langkloof area, Wolwenkop, Rietfontein and the catchment population is estimated at 19647.

There are eight pre-schools, three primary schools, three secondary schools and three high schools in Verena. The other community structures are one drop in centre, two disability centres, nine taverns, eight shops, six spaza shops and nine day care centres.

The Primary Health Care Director also noted that most the Verena community has a high employment rate and those who are working are travelling to Witbank and Gauteng and others are self employed. There is no public transport to Langkloof except hitch hiking and there is also no fixed health facility and that community uses a mobile facility.

The disease profile for the area is HIV and AIDS with 521 adults remaining on ART and 67 children under 15 years also remaining on ART, mental health, sexual transmitted infections (STI), diarrhoea in children under five years, pneumonia and hypertension and diabetes mellitus.

Services that are rendered at the CHC are HIV management including initiation on Antiretroviral therapy, minor ailments, chronic and geriatrics care management, TB management, voluntary HIV counselling and testing, mental health, sexual reproductive health (family planning), antenatal and postnatal care, management of labour and deliveries, rehabilitation, dental and child health care services, communicable disease control services, expanded program in immunization, pre and post counselling for Choice of Termination of Pregnancy (CTOP), post prophylaxis exposure, mobile service with five points, eye care services and the CHC is still going to launch the voluntary male medical circumcision (VMMC).

On referral system Mrs Nelosn noted that Dr Baloyi visits the facility every Friday. The facility refers to Kwa Mhlanga hospital for emergency cases and complicated deliveries. There is no facility that refers to Verena due to its geographical location. Patients who need social services are referred to SASSA on site. The CHC also has a referral register which guide which assist when they referred.

5.1 Governing Structures

The primary health care director highlighted that the CHC works together with the clinic committee that has been appointed and trained and that the committee was nominated to serve for a period of three years. The structure of the clinic committee consists of ten members as follows:

· Chairperson

· Secretary

· Additional members

5.2 Infection Prevention and Control

On infection prevention and control, it was noted that a quality assurance committee has been appointed in January 2013 with terms of reference that outlines their duties and their responsibilities. The infection prevention and control policy and the quality improvement plan are also available. There is a dashboard for tracking and monitoring the six ministerial priorities and the CHC gets feedback from the community on how they progress on those priorities.

5.3 Drug Availability

The CHC has a drug stock register that is available where drugs that are out of stock are recorded. There is a dash board on drug availability has been implemented. There was a 0% in the first quarter for tracer item stock out.

5.4 Human Resources

On human resources, the CHC currently has 18 professional nurses (requires five additional nurses), six enrolled nursed (need three more), e two enrolled nursing assistants (need six more), no pharmacy assistant, no health promoter, four cleaners (need three more) and have no grounds man

5.5 Indicator Report

The community of Verena visit the health centre 3.5 days a year. Pregnant women come late to the clinic and some after five months. The antenatal first visit before 20 weeks was at 28.7% against the target of 40%. The immunisation coverage for under one year was at 66.9% against the 90% target. The community of Verena was not using family planning programme which led to the health centre achieving only 22.4% coverage against the target of 70%. The male condom distribution was at 14.2% against the target of 15%.

5.6 Achievements

Mrs Nelson noted the following as achievements for the CHC:

· The clinic committee has been appointed and trained;

· There is a primary health care outreach team has been servicing the Verena area;

· The health centre has a computer and printer;

· The park home has been completed; and

· The governance structure has been trained.

5.7 Challenges

· There is a shortage of administration clerks to retrieve patients’ files but a submission has been made to appoint an administration clerk.

· There is shortage of office furniture and equipment for new park homes as an extension to the facility. A requisition has been send and the CHC is awaiting procurement and delivery.

5.8 Recommendations

Mrs Nelson made the following recommendations on behalf of the CHC:

· Facility data reviews should be conducted.

· The interior of the facility should be repainted.

· The ceiling in the maternity and VCT section need to be repaired.

· The male staff toilets and carport should be constructed.

· Vacant funded posts should be filled.

6. OVERSIGHT AT ERMELO HOSPITAL

The Committee met with the following delegation at Ermelo Hospital:

Ms Fridah BG Nyathi (Chief Executive Officer (CEO); Ms Nanana Hlatshwayo (Chief executive Officer for the Evander Hospital); Mr Erence Mmola (Deputy Director: Expenditure and Monitoring), Mr Mandla Kamabuza (Assistant Director for Primary Health Care); Mr Moses Siphuma (Assistant Director for Primary Health Care at Chief Albert Luthuli); Ms Faith Dimakatso Mafammer (Deputy Director for Primary Health Care); Ms NE Mnisi (Nursing Service Manager); Mr SI Magaba (Deputy Director for Corporate Services); Mr TM Sonqwenqwe (Project Manager for Hospital Revitalisation); Dr S Mohangi (Project Manager for National Health Insurance (NHI); Mr GS Ntshangase (National Core Standards); Mrs NC Mabaso (HAS coordinator for Albert Luthuli Sub-district); Mrs MA Hattingh (Infection Prevention and Control Coordinator); Mrs LE Oosthuizen (Quality Assurance Coordinator); Dr Thokozani Mhlongo (Deputy Director-General for District Health Services); and Mr VE Khoza (Chief Director GSD).

Ms Nyathi made the presentation to the Committee and gave an introduction to the Ermelo Hospital. She informed the Committee that Ermelo Hospital is a regional hospital (level 2) with 264 approved beds and 216 usable beds. The hospital is within the Msukaligwa Sub-district in the Gert Sibande District. The hospital was officially opened in 1921. It had two wings for the African and White community which were merged in 1994 and made accessible to all racial groups. In 2005 the hospital was placed onto the hospital revitalisation programme. Ermelo Hospital is a referral hospital to all eight district hospitals within the Gert Sibande District Municipality as well as being a referral centre for 11 primary health care facilities within the Msukaligwa sub-district.

The population trends indicate that there is a tremendous growth of 19.7% between 2001 and 2011 and it is currently at an estimated growth rate of 1.8% per annum. The largest age group are adults between the ages 20-49 years which comprises of 67 873 of the population, followed by children between the ages of 10-19 years who comprises 29 048 of the population. The under five year old comprise of 16 574 of the population. females contribute 50.4% and males 49.6% of the total population. Nearly 27% of the population of Msukaligwa are aged between 15-64 years and are unemployed. The leading industries in terms of employment in Msukaligwa are agriculture, community services, and trade. Eighty four percent of the population of Msukaligwa is uninsured and 26.8% is unemployed of these 12.3% of the population above 20 years of age has no schooling.

6.1 Disease Profile

· On disease profile, the sub-district is like the rest of the county as it faces a quadruple burden of diseases like HIV and AIDS, tuberculosis, high maternal and child mortality, non-communicable diseases, violence and injuries. Compounding on these unfavourable conditions are socio-economic determinants of health such as poverty and inadequate access to essential services such as electricity, proper sanitation and access to potable water.

· The HIV epidemic in Msukaligwa sub-district has a profound impact on society, the economy as well as the health sector and contributes to a decline in life expectancy, increased infant and child mortality and maternal deaths. According to the latest Antenatal Care survey for 2011, Msukaligwa sub-district is the third highest in HIV prevalence in the whole of Gert Sibande District, thus the 5^th highest in the Mpumalanga Province. The Anti Retroviral Treatment (ART), Prevention of Mother to Child Transmission (PMTCT) and medical male circumcision programmes is provided within the health facilities in the sub-district.

· Tuberculosis is both a medical condition and a social problem linked to poverty-related conditions. The combination of TB, HIV and drug resistant TB has led to a situation where TB is the number one cause of death among infected patients in Msukaligwa District. TB treatment is provided in Ermelo Hospital and all other health care facilities. Ward based teams in wards 15, 17 and 19 provide support to TB and also support patients on Directly Observed Therapy throughout the municipality.

· The leading causes of death for under one year old age group are pneumonia, diarrhoea and malnutrition. The leading causes of death for under five year old age group are pneumonia and diarrhoea.

· The most common non-communicable diseases within the sub-district is hypertension and diabetes mellitus.

6.2 Emergency Medical Services (EMS)

The state of most of the municipal roads especially the gravel roads are bad with poor storm water drainage. This impact negatively on the EMS response times.

6.3 Budget

The total budget for the hospital for 2013/14 is R193 504 320 with R155 212 000 allocated to the compensation of employees, R36, 258, 000 for goods and services, R136 000 goes to transfers and R1 898 000 for machinery and equipment.

6. 4 Caesarean Section Rate

The CEO informed the Committee that the caesarean rate was 1% above the norm, mostly due to women who had poor progress during labour and pregnancy induced hypertension. To address this, the hospital will conduct morbidity and mortality reviews.

On patient day equivalent (PDE) the CEO noted that it has decreased mostly because there has been a noted decrease in the number of outpatients department (OPD) headcount since May 2013. The reason for the decrease in OPD headcount is the increase in the hours of operation of primary health care (PHC) facilities in Msukaligwa sub-district which now opens seven days in a week for a 12 hour day. The average length of stay is 3.3% above the norm, mostly due to orthopaedic patients. Fourteen of the inpatients with orthopaedic problems could not be transferred due to lack of beds in receiving Witbank and Rob Ferreira Hospitals. To address this challenge the hospital will revive the orthopaedic outreach services.

6.5 Quality Assurance

On quality assurance the CEO reported that the facility has improvement team with a team leader from the National Department of Health. All 12 facilities are implementing facility improvement. The six priority areas of the National Core Standards are implemented and monitored as follows:

· Drug availability is at 91.4%

· Waiting time surveys are conducted monthly and currently the waiting time is at four hours.

· Infection prevention control plan has been developed, implemented and monitored. Staff have been trained on infection prevention and prevention (IPC).

· On staff attitude, a complaint register is implemented with 100% complaints resolved within 25 days. Monthly mini surveys are also conducted.

· On patient safety, morbidity and mortality reviews are conducted, pharmaceutical therapeutics committees conducted, clinical governance committees appointed and standard operational procedures reviewed and developed.

· On cleanliness, a housekeeping manual has been developed, cleaning scheduled and checklist implemented.

6.6 Referral System

On referral system the CEO informed the Committee that Ermelo Hospital refers to Witbank hospital and Rob Ferreira hospital. The hospital faces challenges with referral of orthopaedic cases due to receiving hospitals not having beds. Msukaligwa sub-district does not have a district hospital and therefore all patients from the 11 PHC facilities are referred to this hospital. The EMS station at Ermelo hospital, like all other EMS stations is centrally controlled in Secunda which sometimes causes delays in transporting of patients to upper levels of care.

6.7 Drug Availability

The CEO informed the Committee that the drug availability was at 91.4% and that drugs are ordered from the depot on a month to month contract.

6.8 Primary Health Care

There are three community health care centres (CHC) and eight clinics. One of the CHCs opens for 12 hours, seven days in a week and three of the two clinics opens 12 hours and seven days a week. There were four mobile vehicles which are now scratched off.

6.9 Problem Areas

The following were noted as problem areas by the CEO:

· Shortage of health care professionals

· Shortage of specialists

· Infrastructural challenges and non-functional lifts

· Lack of capacity in the Supply Chain Management unit

· Delayed in the opening of ICU unit due to renovations

6.10 Achievements

The following were noted as achievements:

Output 1: Increasing life expectancy

· Mortality and morbidity meetings are conducted

· Screening of chronic diseases as a part of the health care provider initiated HIV counselling and testing (HCT)

· Rendering of Anti retroviral therapy (ART) to patients and the hospital is initiating the fixed dose combination (FDC) to pregnant women and new HIV positive clients

Output 2: Decrease maternal and child mortality

· Maternal and perinatal deaths morbidity and mortality reviews are conducted monthly

· The hospital has opened a high risk antenatal care and women’s health clinic

Output 3: Combating HIV and AIDS and STIs and decreasing the burden of disease from TB

· All 12 facilities in Msukaligwa are providing HCT and ART

· The nevirapine uptake rate for babies is at 100%

Output 4: Strengthen Health System Effectiveness

· The core management team has been appointed

· The hospital has taken over Sesifuba TB hospital in June 2013

· The hospital is being a benchmark for other districts in terms of pharmaceutical management

· The Hospital has appointed infection prevention and control practitioner that are supporting primary health care

· The availability of TB and ARV drugs is at 100%

6.11 Walkabout

The Committee had a walkabout at the hospital and noticed that the paediatric ward is combined with medical and surgical wards and lifts which have been non functional for three years

7. FINDINGS

The following were findings that were noted by the Committee after visiting the different health facilities:

7.1 Kwamhlanga Hospital had a very high drug stock out rate (14%).

7.2 The Committee also noted that there were many acting positions at KwaMhlanga hospital which took long periods to be filled.

7.3 There was no dedicated maternity ward at Kwamhlanga Hospital.

7.4 The shortage of cleaners was also a concern as this can compromise infection control.

7.5 The issue of referred patients not having dedicated transport was of a concern to the Committee as patients only relied on ambulances.

7.6 There is no dedicated doctor at Verena Community Health Care.

7.7 Re-engineering of Primary Health Care was a challenge at Ermelo Hospital and this was a serious concern to the Committee as PHC is the policy of government.

7.8 There is no emergency ambulance stationed at Ermelo Hospital.

7.9 The Committee also noticed that all visited institutions have a high rate of caesarean sections.

7.10 The high prevalence of HIV and AIDS in the province was also raised as a concern by the Committee.

7.11 The Committee was concerned that the province was not taking urgent actions in addressing the deaths of initiates.

7.12 The caesarean rate was found to be high in all visited institutions

8. RECOMMENDATIONS

The Minister of Health should ensure the following:

8.1 Address the shortage and lack of patients transport.

8.2 Ensure a speedy revitalisation of the ICU unit at Ermelo Hospital.

8.3 Ensure the improvement in the standard of antenatal care so as to decrease high perinatal mortality rate.

8.4 Ensure progress in the implementation of the NHI in Gert Sibande district.

8.5 Devise strategies to decrease infants and under five mortality.

8.6 Establish partnerships in the Gert Sibande district with the mining sector to address the high incidence of HIV and TB.

8.7 The province needs to urgently address the issue of staff shortages, as severe shortages were identified in all health facilities visited.

8.8 The province should ensure that the issue on the deaths of initiates is addressed and should report to the Committee on progress.

Report to be considered.