Report of the Portfolio Committee on Health on the oversight visit to the North West Province from 29 July to 2 August 2013, dated 12 March 2014

The Portfolio Committee on Health (the Committee) having undertaken an oversight visit to the North West Province from 29 July - 9 August 2013 reports as follows:

1. Background

One of the functions of the Portfolio Committee on Health is to conduct oversight over executive organs of state in the national sphere of government under its portfolio in order to monitor the fiscal and programmatic integrity of health programmes; to ensure that funding of these programmes is being provided properly; to safeguard health care quality; and to ensure compliance with legislation, regulations, and other administrative requirements applicable to health care delivery. The Committee therefore conducted its oversight visit in various health institutions in the North West Province from the 29 July to 2 August 2013.

2. Objectives

The purpose of the visit was to assess health care delivery, with special emphasis on quality of health services, infection prevention and control, the referral system, functioning of the primary health care system, roll out of ARVs and drug availability, achievements and challenges with regard to the roll out of the National Health Insurance Pilot Project. The visit also aimed at gaining insight into the functioning and recruitment of retired nurses, how they are compensated and their scope of work.

3. Delegation

The delegation comprised of the following Members of Parliament:

Dr MB Goqwana (Chairperson of the Committee and leader of the delegation - ANC); Ms MC Dube (ANC); Ms TE Kenye (ANC); Ms RM Motsepe (ANC); Ms M Segale-Diswai (ANC); Ms SP Kopane (DA); Ms D Robinson (DA); Mr D Kganare (COPE); and Ms H Msweli (IFP).

The following officials accompanied the delegation:

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

The delegation visited the following public health facilities:

Job Shimankana Tabane Hospital, Boitekong Community Health Centre, Moses Kotane Hospital, Pella Community Health Centre, Mafikeng Hospital, Lehurutshe Zeereust Hospital Complex, Klerksdorp/Tsepong Hospital Complex, Tsepong MDR Hospital and Witrand Psychiatric Hospital

4. Oversight visit to different health facilities

4.1 Job Shimankana Tabane Hospital

Delegation at the hospital:

Dr B Moagi (Senior Clinical Manager and Acting Chief Executive Officer); Mrs EB Mogondsi (Deputy Director Quality Assurance); Mrs R Diphoko (Nursing Service Manager); Mr MT Khoygoana (Deputy Director Corporate Services); Ms M Rakau (Chief Director); Dr F Reichel (Director HOD Support); and Ms R Lobeko (Media and Communication).

Dr Moagi led the delegation and tendered an apology for the CEO who could not be present due to other engagements. Dr Moagi welcomed the delegation and made a presentation focusing on the background of the hospital; services rendered; progress on the six ministerial priority areas; and highlighted their successes and challenges. Job Shimankana Tabane (JST) Hospital is a level two provincial (regional) hospital in the Bojanala District in the North West Province. The hospital was founded in 1923 by the Rustenburg Rate Payers Association and the first building was completed in 1927 and named Paul Kruger Hospital. In 1997, the hospital was configured a regional hospital and named Rustenburg Provincial Hospital. In 2008 it was re-named Job Shimankana Tabane Hospital. Dr Moagi went on to say that Job Shimankana Tabane was an activitst and he hailed from the Maile Village, 35 kilometres outside Rustenburg. The Maile village is part of the cluster of Batswana ba Phokeng villages that are under the Royal Bafokeng Administration.

Rustenburg’s economy is led by mining activity and the greater part of its population is rural and is influenced by migrant labour system from all over Southern Africa. The hospital serves as a referral hospital to four of the five sub districts, especially the Swartruggens/Koster, Brits and Moses Kotane District Hospitals.

The hospital has 396 approved beds and 316 usable beds, 14 neonatal Intensive Care Unit (ICU) beds, six adult ICU beds, 30 beds in the accident and emergency department. Sixty beds were reduced because of the unsafe building and a 20 bedded ward was converted to a dialysis unit.

Bojanala district comprises of the following sub-districts and facilities:

• Moretele which has no hospital and no community health centre;
• Madibeng-Brits district with a hospital that is under construction and two community health centres;
• Rustenburg which has no district hospital and three community health centres;
• Moses Kotane which has Moses Kotane district hospital and two community health centres; and
• Kgetleng – Swartruggens which has Koster district hospital complex.

4.1.1 Services provided at the hospital

Accident and emergency services including family medicine, Obstetrics and Gynaecology, reproductive health and Choice on Termination of Pregnancy (CTOP) services, Paediatrics, Neonatology, Internal Medicine, HIV and AIDS wellness clinic, General Surgery, Orthopaedic, Mental Health, Anaesthesia, adult ICU, Neonatal ICU, Radiology serviced including CT scan, Ophthalmology, Renal Services and Complex Orthopaedic like Joint replacements.

Allied health services provided are speech therapy and audiology, occupational therapy, physiotherapy, radiography, social worker services, psychology services, dietetics services and pharmaceutical services.

Services provided within the hospital premises but not by the hospital are dental, emergency medical rescue, pathology which is provided by the National Health Laboratory Services (NHLS), South African National Blood Services (SANBS), Forensic pathology and Road Accident Fund.

Highlights of the hospital include a state of the art renal unit which was officially unveiled on the 27 February 2012; refurbished outpatient department, refurbished accident and emergency admissions, and treatment areas and the resuscitation ward.

Projects that were unfolding were medical ward, surgical ward, mental health ward, ICU and revamping of the theatre. Projects that were cancelled due to budgetary constraints were maternity obstetric unit, dedicated unit for mother and child services, as well as Boitekong Health Centre extensions to improve maternity section.

Dr Moagi provided the committee with a report on a planned provincial tertiary hospital, the business cases for a new hospital in keeping with August 2011 Gazette that states that the North West Province should have provincial tertiary hospitals in Rustenburg and Klerksdorp.

4.1.2 Progress report in relation to the six ministerial priorities

1) Cleanliness

• The infrastructure is old, however the hospital is clean. The hospital participated in a competition, adjudication was conducted but still waiting for results.
• Essential equipment and cleaning materials have been procured.
• Training on cleaning and policies were offered to cleaners and operational managers.
• Materials out of stock from central depot were bought out of contract. Cleanest competitions are held weekly with all sectional managers. Two peer reviews on cleanliness were also conducted.
• Orders for patient’s blankets and gowns were received in June 2013. The Hospital received a compliment in the June article of the local newspaper on cleanliness.

2) Infection prevention and control

• Nosocomial infection were recorded at 1.2%.
• There is a dedicated infection prevention and control coordinator and a training plan on universal precautions is currently being drafted for patients, staff and public.
• All PPE’s in stock, contingency plan were in place for those not in stock from Supply Chain Management and Mmabatho depot and extra stock from other units was evenly distributed or to those units in need.
• Protective clothing for general workers and clinical staff were ordered and those for general workers were received in June 2013.
• Internal staff assessment for National Core Standards (NCS) was done by managers.

3) Positive and caring attitudes

• Staff attitude remained a challenge though it had improved.
• Training of managers and personnel on Batho Pele Principles and change management was done.
• Other strategies to improve attitude were unfolding like forming task teams and plans were in place for their analysis.
• Feedback was given to staff through monthly meetings and quarterly mass meetings including other scheduled meetings.
• Complaints were managed and resolved according to the complaints management policy by sectional complaints managers and quality assurance.
• Reports of staff misconduct are reported, code of conduct and policy signed, distributed to all departments for staff to sign.

4) Patient safety and security

• Perimeter fencing was changed in 2011 from pourous mesh fence wall. This reduced the number of entrances and exits.
• Outsourced security remained a risk following challenges of the supplier with the South African Revenue Services (SARS).
• Training of health professionals from different disciplines including other categories on NCS and six priority areas was provided.
• Internal self assessment using the core standards questionnaires was conducted quarterly to assess standard adherence from clinical and non clinical areas.
• Monthly mortality and morbidity meetings in medical disciplines, patient safety group (PSG) and pharmaceutics and therapeutics committee (PTC) meetings were conducted.
• Daily checking of critical equipment by different units to ensure functionality and maintenance was done according to maintenance plan by health technology manager.

5) Waiting times

• The Kaizen Model which won international award for reducing patient waiting times was rolled out to different units. Reports on waiting time was measured and submitted to quality assurance and the average for June 2013 was 172 minutes.
• Triage and sorting of patients in outpatient department (OPD) were done daily to improve waiting times.
• Continuous training of personnel on NCS and ministerial directives to address the waiting time in all units will be conducted.

6) Availability of medicines and supplies

• The hospital was at 91-94% during the time of the visit.
• Weekly ordering and delivery of medicine, back orders were received monthly.
• Both the ARV and TB treatment were at 100% available.
• Male condoms were distributed to JST outlets and there was no shortage reported.

The following challenges were reported on drug availability:

• In August 2012 the hospital was at 76% due to suppliers being unable to meet hospital orders.
• There was a gap between the new and the old contractor as the new contractor was given 90 days to deliver and yet the old one had expired.
• The NWP medical depot system was also not functioning properly.

4.1.3 Mother and Child Health services

• The JSTH mother and child health services is led by: one full time obstetrician and gynaecologist and four part time specialists; team of midwives and advanced midwives; and trained neonatal ICU nurses.
• The four district hospitals and numerous clinics refers complicated obstetric patients to JSTH for definitive management.
• All neonates were managed at JSTH.
• On average approximately 420 deliveries per month are managed at JSTH.
• On average, there were 30 and 46 admissions in neonatal ICU and neonatal ward, respectively.

4.1.4 The following challenges were highlighted:

• Inadequate infrastructural resources at JSTH has not grown with the growing city and population it serves. A remedial action is a new hospital in Rustenburg to serve as a level two whilst existing hospital becomes level one.

• There is no level one hospital in the Rustenburg sub-district. An addition of a 24 hr Community Health Centre needs to be established in the city. Primary Health Care and level one hospitals need to be strengthened so that they can provide adequate package of services.

• There is no access to tertiary hospital in NWP, referrals to Gauteng Province tertiary hospitals is very difficulty especially Dr George Mukhari Hospital and Steve Biko Academic Hospital. Gauteng Province and the tertiary hospitals have a contract with NDOH that as beneficiaries of the National Tertiary Services Grant they are to provide listed tertiary services. More than R2.3 million has been allocated to the hospital for this purpose. Dr Moagi noted that this information may not be known to the clinicians and specialists who are denying patients this access and perhaps administrators with this information should ensure that it filters to all clinicians and that all comply.

• There is poor antenatal clinic attendance or care which leads to complications later in pregnancy. Many come to Bojanala because of their partners or husbands who work in mines and they would not have had any antenatal clinic from where they come from. A remedial action is to strengthen Basic Antenatal Care (BANC) training and practices. Training has occurred at PHC but implementation is poor.

• Another challenge is the number of illegal unsafe abortions which leads to the high maternal death rate. This is compounded by insufficient service points providing for the service. To remedy this challenge the hospital will increase service points providing safe abortions and therefore improving accessibility.

• The inequality in resource allocation in the NWPDOH was also noted as a challenge. The less densely populated districts have better human and budgetary resources and the more populous Bojanala district was less resourced with poor health outcomes. There’s a need for a revision of resource allocation model like infrastructure development for cancelled projects and equitable allocation of persal post.

Having concluded the briefing, the delegation went on a walkabout in the hospital and visited the following wards:

i. Maternity Ward

The ward was a six bedded unit and Sister Distele informed the delegation that they had bed shortages and when the ward is full they have to extend to other wards.

ii. High Care

There were bed shortages and had to extend to other wards when full. Staff shortages were also prominent in the ward, with three midwives and two nurses per shift of four shifts.

iii. Labour rooms

Space shortages were also highlighted in the labour rooms. This was illustrated by the fact that the high care, labour unit and the antenatal unit were in the same ward. There was only one oxygen machine which services the six beds instead of each bed having its own oxygen supply.

iv. Emergency unit

There was no security gates at the emergency unit and people can just walk to the unit from outside, this presents safety concerns

v. Renal Unit

The renal unit used to be a female surgery. The unit is well equipped. They use guidelines from the South African Renal Association as well National Guidelines.

4.2 Boitekong Community Health Centre

Delegation at the Community Health Centre:

Ms E Moladisi (Assistant Manager Nursing); Ms ME Rakau (Bojanala District Office); Ms R Moseneke (Operational Manager); Mr L Tlhowe (Rustenburg Sub-district Manager); Ms J Thuppe (Assistant Manager); and Ms R Lebeko (Media and Communication).

Ms Moladisi informed the delegation that Rustenburg sub-district is the largest of the five sub districts in Bojanala with an estimated population of 549 775 according to 2011 census. It has a total of 22 facilities including the then local municipality clinics which are four. The facilities are clustered in three namely Thibane, Bafokeng and Boitekong. There is a total of 10 PHC mobile clinics (including Rustenburg Platinum Mine and Royal Bafokeng Administration) and one dental mobile clinic. Boitekong cluster constitute 40% of the population of Rustenburg sub-district.

Services rendered are PHC, Maternal, Child and Women’s Health (MCWH), reproductive health, communicable diseases (TB, HIV/AIDS and ART), emergency services, immunisation, mental health, male medical circumcision and oral health services.

Ms Moladisi noted that the workload for the CHC is heavy based on the complexity of conditions managed, patient waiting times is prolonged with an average of 5-6 hours against the norm of 3 hours. To minimise this workload and reduce waiting times the following strategies were introduced:

• Stable chronic patients are given two months supply of medication. This impacts on total headcount which seems to go down as compared to the expenditure on medicine.
• Booking system is intensified.
• Files for booked patients are drawn a day before the appointment day and the challenge is during weekends when clerks are not available.
• Fast queues for specific types of patients.

4.2.1 Challenges

The following challenges were noted:

4.2.1.1 Staffing

• There is no separate staff for maternity and emergencies/casualties as informed by statistics. The CHC experienced large numbers of these types of clients.
• There is no support staff like cleaners and clerks after hours. Nurses retrieve files and wipe the floors when these categories are not available. This has a direct impact on waiting time and infection control.
• Insufficient speciality staff such as midwives, trauma trained etc.
• There is no doctor on call after hours.
• There is inadequate budget to fill the posts and convert some existing posts to address staff shortages.

4.2.1.2 Equipment

• The equipment is not enough in numbers for the clinicians and not technologically advanced.

4.2.1.3 Security

• There are not enough security guards and are not equipped (not armed) for the types of risks in the area.

4.2.1.4 Maintenance

• There are delays in attending to maintenance needs.
• There is no artisan on site to attend to minor maintenance work.
• There are challenges with public works.
• Medical equipment repairs are done by technicians in JST Hospital.

4.2.1.5 Physical structure

• There is inadequate space
• There is only one waiting area for clients including children which compromise infection control and queue management.
• There are five consulting rooms for nurses, doctors, students and other health professionals which is far from enough. The boardroom is used as a consulting room. There is one counselling room. A store room and the nurses station in the maternity wing are used as additional counselling rooms.
• There are inadequate beds in the maternity ward leading to patients sleeping on the floor.
• There are no observation rooms for stabilising patients.

4.2.1.6 Communication

• There is no internet network in the centre.

4.2.1.7 Community issues

• Communities are using untraceable physical addresses which becomes a challenge in contact tracing.
• There is failure in the community in taking responsibility for their own health.
• Staff experience aggression especially during weekends.
• There is a language barrier especially Portuguese and Chinese.
• Community members do not honour their appointment days.

The delegation went on a walkabout at the health centre and noted the following:

i. Waiting Area

There delegation observed extremely long waiting times. The time was around 16:00 in the afternoon and when patients were asked how long they have been waiting they told the delegation that they had been waiting since 6 o’clock in the morning and have not yet been attended to.

ii. Pharmacy

There was no dedicated pharmacist in the pharmacy and they use services of a regional pharmacist. There was only one pharmacy assistant working in the pharmacy on the day of the visit.

iii. Patient files

There seemed to be no efficient filing system for managing patients medical records. This could also be a contributory factor to the long waiting times.

4.3 Oversight at Moses Kotane Hospital

Delegation from the Hospital:

Ms M Mabe (Director District Hospital Services); Ms ME Scheepers (Acting Chief Executive Officer); Dr GS Mangwame (Clinical Manager); Ms R Lebeko (Media and Communication); Ms H Seemela (Assistant Manager-Nursing); and Ms K Khunou (Acting Deputy Director - Administration).

The acting CEO Ms Scheepers led the delegation and briefed the delegation, starting off with the vision and mission of Moses Kotane and also gave a background of the hospital. Moses Kotane Hospital is a new revitalised hospital situated in Moses Kotane Local Municipality within the Bojanala District. Moses Kotane is a 230 bedded hospital serving 254 796 population and a referral for 45 clinics and four health centres and referral for level two services at JST Hospital. The hospital was occupied on the 17 May 2010 while still under construction. The final handover of the hospital took place on the 21 July 2011.

4.3.1 Services rendered at the hospital are as follows:

Outpatient Department (OPD), casualty and emergencies, obstetrics and gynaecology, medical, surgical, paediatrics, high care, theatre, occupational health, choice of termination of pregnancy (CTOP), Comprehensive Care and Treatment of HIV & AIDS, radiology, pharmacy, speech and audiology, occupational therapy, physiotherapy, social services, dietetics, dental and laboratory.

4.3.2 New units and services are as follows:

Ten bedded high care, six bedded neonatal ICU which will be operational soon, six theatres, casualty and emergency unit, 15 bedded private unit, clinical engineering, helipad and 39 residential units.

4.3.3 Opportunities for the Hospital:

Digital X-Ray, private ward, second phase of the hospital and nursing school.

4.3.4 Hospital achievements

The following were noted as achievements for the hospital:

• The hospital participated in the provision of health services during the 2010 World Cup.
• The hospital is being classified as the best facility in waste management.
• The hospital has received the cleanest hospital award.

4.3.5 Improving service delivery

The hospital has identified and implemented the following strategies:

• Team approach quality rounds, Management by Walking Around (MBWA) at least twice a day.
• Area managers are to visit their units daily to check for compliance.
• Inspections are going to be conducted by quality assurance unit.
• There is development of monitoring tool/checklist by managers.
• Continuous training and development will be introduced.
• MBWA by both IPC and cleaning supervisors.
• Cleaners will be allocated on night duty mainly to cover OPD and casualty.

4.3.6 Challenges

Ms Scheepers informed the delegation that the hospital is facing the following challenges:

• There is no residential units for nursing students;
• High mortality rate due to the high burden of disease;
• Late presentation for treatment by patients;
• Self referrals and referrals to level two which is due to people bypassing clinics;
• Human resources shortages;
• Insufficient budget;
• Underutilisation of theatres;
• Transport shortages;
• Infrastructure defects; and
• Poor quality of security.

Having concluded the meeting the Committee had a walk about in the hospital and noted the following:

• There were visible structural defects such as cracks on the walls and peeling off in some areas.
• The delegation observed about two empty rooms that could have been utilised by the hospital and the explanation was that some equipment were taken from the hospital to JST Hospital and there was nothing given to the hospital to replace these.
• An X-ray machine was incorrectly installed making it difficult to use and has never been used since its installation.

4.4 Oversight at Pella Community Health Centre

Delegation from the hospital:

Mr KS Boikanyo (Sub-District Manager); Mrs M Mabe (Director - District Hospital Services); Mr BP Mekgoe (Facility Manager); Mrs SS Moabi (Assistant Manager-Nursing); Ms ME Bolokwe (Director District Health Services); Ms R Lebeko (Media and Communication); Mr L Kolobe (Parliamentary Liaising Officer); Dr S Mangwane (Clinical Manager); Mr R Mosome (Village Speaker - Executive Council); and Mr T Sokoko – Traditional Representative.

Mr Boikanyo made his presentation and gave a background and context of the district health system. He mentioned that the White Paper for the Transformation of the Health System in South Africa (1997) firmly positioned Primary Health Care as a strategic approach for developing a unified health system capable of delivering health care to all citizens of South Africa efficiently in a caring environment. This emphasizes the need to decentralise the management of health services with an emphasis on the District Health System (DHS) to increase access to Primary Health Care (PHC), in ensuring safe and good quality outcomes and to rationalise health financing through budget re-prioritisation.

He also noted that post 2009 elections, government ushered in two key developments namely; the Green Paper on the National Strategic Planning by the Ministry of Planning towards the development of the National Plan 2030 and a Monitoring and Evaluation competency framework in the Presidency which not only gave impetus to the strategic planning process but also led to the development of the National Development Plan 2030 and the signing of the Negotiated Service Delivery Agreement by Cabinet.

Mr Boikanyo informed the delegation that the Health Centre has aligned its five year strategic plan (2009 -2014) and the annual performance plan with both the NDOH ten point plan as well as the NSDA. Similarly all the four districts constituting the NWDOH namely; Bojanala, Dr Kenneth Kaunda, Dr Ruth Segomotsi, Mompati and Ngaka Modiri Molema Districts have ensured proper alignment to the NDOH and Provincial Department of Health (PDOH) strategies. Sub-districts and hospitals have also followed suit and Moses Kotane sub-district is no exception.

He also noted that the majority of the population in the sub-district is black which is 98.2%, whites 0.75%, Asian 0.49% and coloureds were the lowest population of 0.25%. In terms of gender and age, the majority of the population is 49.68% females and 50.31 males. The 24.5% of the total population is between the ages of 12 and 18 and the 38% of the population is between the ages of 60 and 70 years.

He noted that pre 1994 dispensation saw the health sub-district having three district hospitals which were Derdepoort Hospital which was closed in 2005, Moreteletsi Hospital which was closed in 2006 and George Stegman Hospital which was later revitalised and became known as Moses Kotane Hospital. Transformation of health services has been achieved given the number of health facilities within the sub-district.

4.4.1 Socio Economic Factors

The overall unemployment rate is 38% with the youth unemployment rate at 43.2%.

4.4.2 Health Profile

The sub-district has 50 health facilities within four health areas which are one district hospital, Mogwase Cluster with one Community Health Centre and 12 clinicis, Mabeskrall one community health centre and 13 clinics, Pella Community Health Centre, 10 clinics and Sesobe with 12 clinics , 36 mobile points and four health posts. On emergency services, there is one station at Moses Kotane, two satellite stations at Mogwase and Mabeskrall as well as night service ambulance at Mokgalwaneng clinic. The total number of private general practitioners in the whole municipality is 11 with no private hospital.

4.4.3 Services rendered

Preventative, promotive, rehabilitative, curative, and other support services like pharmaceutical and laboratories.

4.4.4 Referral System and ARV Rollout System

All clinics within the cluster refer to the respective community health centre and equally primary health care facilities refer to Moses Kotane Hospital for all level one hospital services.

For secondary and tertiary health services Moses Kotane Hospital refers to JST Hospital which has a Memorandum of Understanding with Dr George Mukhari Hospital in Gauteng for tertiary and other special services. In 2012 the NWDOH HART Chief Directorate certified all the 49 health facilities to provide ARV’s even though there has been challenges in those facilities with one professional nurse.

The Health Centre has developmental partners namely; the ITECH and AURUM institute which assist them with the provision of training. These have been handy in training nurses on pulsa plus (14) and NIMART (55). Challenges in ARV stock outs were only experienced once around January 2013 which was a result of supply from the provincial depot.

Phasing in of the Fixed Dose Combination (FDC) have been smooth and no challenges experienced thus far. Challenges have been with supply of other medicines and drugs from the hospital either due to the non cooperation of the hospital pharmacy manager or stock outs. Joint management meetings (Hospital and sub-district) were held to resolve the matter. Operational managers also assist in reporting al stock out items to their respective cluster managers who in turn inform the office of the CEO and the SD pharmacists.

4.4.5 Preparation for the National Health Insurance (NHI) and Re-engineering of Primary Health Care (PHC)

In preparation for the NHI the presenter noted the following;

Bojanala has no NHI pilot project and DR Kenneth Kaunda District is the provincial site and preparations for the roll out are preceded by the implementation of among others through re-engineering of PHC and national core standards, the sub-district re-engineering pilot site is Tweelegte Village Ward 24 which has a population of 9530. The SD has rolled out to nine wards.

4.4.6 Re-engineering of PHC

With regard to the re-engineering of PHC, the CHC is in the process of recruiting retired nurses. All appointed retired nurses are paid according to the Occupational Specific Dispensation (OSD) with Grade three being the standard notch. The retired nurses have been deployed mainly according to their local places or abode and most are in Mogease Cluster. He also informed the Committee that school health services have started in June 2013 after the appointment of retired nurses.

4.4.7 Revitalisation projects

The sub-district has no departmental revitalised site, all projects are sponsored by mines and Sun City (which are Sefikile Clinic which is 85% complete and Bakubung Clinic which is undergoing upgrading).

4.4.8 Recommendations presented by the sub-district office

Mr Boikanyo noted that the provision of excellent quality primary health care services is dependent on resources like staff, vehicles as well as equipment and budget. He recommends that the sub-district be afforded the opportunity to increase its staffing of nurses in clinics, procurement of pool cars and or subsidy vehicles. He also recommended that the budget for goods and services as well as equipment be increased.

4.5 Oversight at Mafikeng Hospital

Delegation from the hospital:

Mr AE Lourens (Chief Executive Officer); Mrs MJ Moromane (Deputy Director – Nursing); Dr TNC April (Acting Senior Clinical Manager); Mr M Madiwa (Acting Deputy Director – Corporate Services); Mr LR Lebotse (Acting Director – Finance); Mr L Kolobe (Parliamentary Liaising Officer); Ms M Tapologo (Assistant Manager – Nursing); Mrs D Lingiwe – (Assistant Manager – Nursing); Mr John Smith (Assistant Manager – Pharmaceutical Services); and Ms D Sibongile (Assistant Manager – Nursing)

Mr Lourens made the briefing and informed the delegation that late referrals remained a problem on high risk cases which leads to maternal deaths which could have been avoided. The remedial action to this challenge was to speed up the functionality of maternity waiting home. The average length of stay (ALOS) is six days and the bed utilisation rate is 75%. Performance was above target due to payment of accruals in May 2013. The hospital had a challenge of broken laundry washing machines and boiler and that they were taking their laundry to Klerksdorp and also using private companies.

In compliance with the six priorities of the core standards he noted the following:

• Drug availability was at 71%, instead of 93%;
• Cleanliness was at 77% as opposed to 87%;
• On patient safety and security, there were nine abscondments reported and nine recaptured and security has been distributed to all vulnerable areas;
• Staff attitude was at 19.6%;
• Waiting time at 2hrs and 42 minutes; and
• Infection control 0.3%.

It was noted that for the first quarter the hospital had nine maternal deaths which were all HIV related. On nosocomial infection rate, the hospital was still meeting the target on performance but they were still experiencing delays in getting results on time from the laboratory and the matter was being attended to by the laboratory.

The delegation went on a walkabout at the hospital and noted the following:

i. Ward nine

On the day of the visit there were six beds in a four bed unit. Staff shortages were also reported, the ward has only eight nursed during the day instead of 12. There was no privacy between the patients as there were no curtains between the beds. Wall paint was peeling off in the ward.

ii. Intensive Care Unit

The sister in charge informed the committee that the ICU was 80% understaffed. They have 14 registered nurses instead of 25. They use old models of ventilators that were bought in 1997. Of the old ventilators, only three are functioning.

4.6 Oversight at Lehurutshe/Zeerust Hospital Complex

Delegation from the hospital:

Mr N Mosiane (Chief Executive Officer); Ms ME Kaudi (Director – Hospital Services); Ms MH Kgatitsoe (Deputy Mananger – Nursing); and Dr BS Belle (Clinical Manager).

Mr Mosiane briefed the delegation and provided a background of the hospital complex. He noted that Lehurutshe and Zeerust hospitals are two hospitals that operate as hospital complex and are 17 kilometres apart. The hospital serves a population of about 143 095 in Ramotshere-Moiloa sub-district. The hospital complex serve as a district hospital to four health centres, 16 clinics, two health post and six mobile clinics in Ramotshere-Moiloa Sub-district. The hospital complex provides level one hospital services in terms of the District Health System in Ngaka Modiri Molema district. The hospital complex is managed by one management team consisting of CEO, clinical manager, nursing service manager and Administration Manager.

Services that are provided at Lehurutshe are OPD and casualty paediatric, maternity, female wards, theatre, X-ray department, physiotherapist, occupational therapist and social work services, pharmacy and wellness clinic. The hospital has two infection control coordinators and they manage IPC and TB programmes.

Zeerust offers an outpatient department and casualty male and female wards, theatre, X-ray department, physiotherapist, occupational therapist and social work services, pharmacy and wellness clinic. In terms of referrals, the hospital complex refers patients who need level two services to MPH and BPH for psychiatric services.

On staff complement, the hospital complex is served by 335 staff members, 172 at Lehurutshe and 163 at Zeerust with two retired nurses at Lehurutshe. Among the staff members the hospital is having a total of 13 doctors who are pooled together and managed by one clinical manager. The doctors operate from the hospital and do outreach to clinics and health centre and they are also complemented by sessional doctors who are serving the hospital after hours.

Mr Mosiane also noted that the hospital complex was implementing and monitoring the key six key priorities:

• Cleanliness of hospital environment
• Infection Prevention and control
• Drug availability
• Safety and security of patients and staff
• Patient waiting time
• Staff attitude

4.6.1 Drug availability and FDC

Drug availability was at 96% in terms of EDL (Essential Drugs List) for district hospitals. ART patients started on FDC were 113 and 81 for Lehurutshe and Zeerust, respectively.

4.6.2 Budget

The budget allocation for 2013/14 was as follows:

• Compensation of employees : R74 922 000
• Goods and Services: R26 739 698
• Machinery and equipment : R766 00
• Household: R95 000

4.6.3 Challenges

- Perinatal mortality is high which is thought to be due to induced illegal abortions.

- Patient transportation remains a challenge.

- Lack of laundry services within the hospital premises.

Having concluded the meeting the committee was taken on a tour of the hospital and noted the following:

There is a well equipped training centre. The centre is for students from the faculty of health science at the University of Witwatersrand. The centre is a collaborative partnership between the North West Department of Health and the University of Witwatersrand. Accommodation for the students is provided by the hospital. The budget for the centre is held by the district.

4.7 Oversight at Klerksdorp Tshepong Hospital

Delegation from the hospital:

Mr P Mokatsane (Chief Executive Officer); Mr Mobai (Deputy Director – Corporate Services); Mrs MM Dikane (Deputy Director – Nursing); Mrs JJE Oosthumer (Deputy Director – Quality); Mr J Drotskie (Administrative Manager); Mrs M Dichabe (Core Standard Manager); Dr M Diching-Mahole (Clinical Manager); Ms K Randeree (District Hospital Services); Dr U Nagpal (Programme Manager – NHI); Dr MD Leburu (Clinical Manager); Mr A Chabedi (District Coordinator – NHI); Mr L Kolobe (Parliamentary Liaising Officer); Ms M Mabale (Protocol Officer); Ms N Mojanaga (Chief Director – District); Mr K Ndincede (MME Health); and Ms NS Mendela (Councillor).

Mr Mokatsane made the presentation and gave the vision, mission and values of the province. He highlighted that their reputation for caring and serving stems from the African tradition of ubuntu. To do this the hospital manages its resources efficiently and responsibly. Their strength lies in creating an environment that respects and welcomes diversity of faith and cultures. The hospital also recognises its special responsibility to the poor.

The Klerksdorp hospital is 829 bedded developing tertiary hospital complex situated in Dr Kenneth Kaunda District in the Matlosana sub-district. Of the 829 beds, 467 beds are in Klerksdorp, 382 beds are in Tshepong and 98 are at the MDR/XDR centre. Nine of the ten theatres are functional in Klerksdorp and five are in Tshepong. The hospital renders 24 hour level one services for Matlosana, level two for Dr Kenneth Kaunda and level three for the whole province.

4.7.1 Services provided at the hospital are as follows:

Radiology, pharmacy, paediatrician, orthopaedic, ophthalmology, Radiation oncology, renal, anaesthesia, internal medicine, wellness MDR/XDR, laboratory, catering, provincial laundry, information technology, Thuthuzela, Male Medical Circumcision and HCT.

4.7.2 Challenges and interventions

On challenges the CEO mentioned the following with possible interventions:

• Staff attitude – staff engagement conducted and expected daily behaviours is that the staff greet the patients and ask for permission if they need to conduct any tests and thank the patient afterwards.
• On waiting times - there are queue management staff who attend to patients.
• On lack of capacity - is in-house capacity building and alternative funding initiatives are taken.
• On the issue of obsolete HCT - there is maintenance and replacement plan that focuses on life support.
• On shortage of hospital beds - there is a decongestion plan.
• Staff shortages - the AHP will assist to recruit in the shortage of specialists and nurses.
• Introduction of ward-based electronic data system and information audit has been conducted to address the inadequate date management.
• The patient bell system and a security plan have been introduced to attend to security issues.

4.7.3 Primary Health Care

· There is a functional district health council, hospital boards, governance structures and clinic committees.

· All health facilities are provincialised.

· Functional district management teams are in place to guide primary health care re-engineering.

· District Clinical Specialist Teams (DCST) have been appointed and functional.

· School health teams have been established.

· Seven hundred and sixty community health workers have been employed on persal.

· Two hundred and twenty one community health workers have been deployed in primary health care engineering.

· Fifteen primary health care nurses have been deployed in primary health care re engineering.

· Three hundred and twenty seven community health workers have been trained on ward based approach.

· Twenty five primary health care nurses have been trained on ward based approach.

· Forty-one (41) retired nurses have been appointed.

· In addressing the Intergrated Chronic Disease Management (ICDM) fast lanes have been introduced and issuing of two to three months medication to patients who adhere to treatment.

4.7.4 Progress on the National Health Insurance

Dr Nagpal presented on progress and challenges during the first 15 months of the implementation of the NHI in the North West and noted the following:

• Dr Kenneth Kaunda District was declared as an NHI pilot district in March 2012. A conditional grant budget of 11.5 million was received in 2012/13 and 4.85 million in 2013/14.
• One of its achievements is that in the first year the emphasis was on strengthening district health services and primary health care reengineering.
• Facility improvement teams were also established at provincial and district level and were supported by the national fit team.

4.7.4.1 District Health Systems Strengthening

On district health systems strengthening Dr Nagpal noted that:

• Five subcommittees were established with experts and representation from sub-districts and district office as follows:

ü Infrastructure management

ü Equipment

ü Pharmaceuticals

ü Quality and

ü Human Resource planning and development.

4.7.4.2 Projects undertaken are as follows:

1) Facility infrastructure

• Twenty facilities were assessed by experts reporting on condition of facility, maintenance required and the bill of quantities.
• Recommended work has been completed in some and ongoing. Minor maintenance work was done in all districts and maintenance projects completed at a cost of 8.577 million from equitable share.
• Work was commissioned for 22 clinics and all nine health centres. Repairs, replacements and earthing, covering of wires etc was done in all the above referred facilities and they now have compliance certificates.

2) Equipment

• Minimum equipment needs analysis has been completed.
• Medical equipment procured and distributed.
• Equipment team involved in developing equipment maintenance plans.
• IT equipment needs also completed. All primary health care facilities have been provided with needed IT equipment.
• All equipment required for specialist outreach teams, school health teams and master trainers have been procured.
• Equipment for community health workers to screen chronic diseases and communication is being procured.

3) Pharmaceuticals

On pharmaceuticals the following were noted:

• A pharmacist assistant (post basic) was employed at Grace Mokhomo Community Health Centre. The Centre showed the most improvement on drug availability and waiting times. The availability improved from 70% to 83%. The pharmacist assistant assisted Kanana Clinic and it also showed drug availability improvement from 61% to 81%.
• Twenty pharmacist assistant that were trained on the basic course last year are being trained on post basic.
• Revision of standard operating procedures for clinic pharmaceuticals services was done.
• Hospital and sub-district pharmaceutical and therapeutic committee meetings have been strengthened.

4) Quality assurance

· Inspection of facilities has been completed. Reports have been given to sub-districts on cleanliness, infection prevention and control, patient safety, drug availability, staff attitude and waiting times to make improvements. Improvements have been noted in most facilities. Others will benchmark with best practicing institutions.

· Customer care training and cleanliness training conducted.

· Self assessment for compliance to National Core Standards has been completed in all facilities in the district.

· Terms of reference for functioning of the district National Core Standards and sub-district teams has been signed off by the Chief Director and schedule for visits to facilities has been concluded.

5) Human Resource Management and Development

· Regional training centre (RTC) has been established at the previously redundant nurses home in Tshepong hospital through renovations.

· RTC manager has been appointed.

· Equipment has been procured.

· Clinical associates have been housed on top floor.

· In-house training was done to save costs on venue.

· Master trainers have been trained.

6) Strengthening District Health Services Training

• Training has been completed in preparation for the implementation of the NHI.
• Training in finance for non financial managers has been conducted.
• Training of governance structures in Monitoring and Evaluation has been conducted.
• Family physicians were trained in PMDS to manage contracted GPs.
• Cleaners were afforded a cleaning course.
• Training on infection control in ambulatory facilities was provided to EMRS and mobile staff.
• Computer training to data capturers and clinic clerks was conducted.
• The training of staff in demand planning, acquisition and asset management has been arranged and will take place in the second quarter.
• The team working on the WISN (Workload Indicators of Staffing Need) project has completed its work. The report has been submitted.
• The referral policy for the district has been revised by the specialist outreach team to include referrals by community health workers and school health.

7) Governance

On governance the following were noted:

• All levels of governance structures are established and functional and training conducted.
• The other districts that are not piloting have been invited to meetings so that their development and ability to implement NHI is simultaneously strengthened through their equitable share.

8) Financial Performance

• NHI expenditure for 2012/13 was at 76% and including commitments at 96%. Rollover for committed orders has been requested..
• The remaining 4% was not spent as it was for specialist teams and they were appointed late.
• Expenditure to date for this year is as 20% and with commitment at 26%.

9) Challenges and proposed interventions

The following challenges on NHI and proposed solutions were noted:

• Funding for NHI is inadequate as only 4.85 million has been allocated out of 26 million.

• Retained funds at National Department of Health were for appointing GPs and for facility improvement. To date only three GPs have been appointed in the district and there is no money spent by the National Department of Health (NDOH) on facility improvement. It is unlikely to be spent and may have to be returned. A quick evaluation of how much will be required and allocation of the remaining two districts will assist in wise spending on much needed equipment and maintenance. Centralising appointments and expenditure at national level leads to delays in implementation. It also gives a message of inadequacy to service level staff and is demoralising. It is also contrary to NHI requirement where decentralising is the key.
• Despite the advantages of economies of scale in centralisation process, the decentralisation needs to happen.
• The district does not have enough staff nor funds to establish a planning, monitoring and evaluation unit.
• The National Core Standards need to be met for the NHI success. Neither the district structure nor budget will be able to appoint someone for quality assurance. The Provincial unit may work offsite to ensure accreditation and readiness.
• Shared services at district/sub-district level may help alleviate staff shortages in rural areas in Supply Chain Management (SCM) and finance.

Having received the presentation and raised immediate concerns the delegation went on a walkabout, and noted that the hospital has implemented admirable innovations such as the introduction of labour companions at the maternity unit. This is lauded as one of the first innovations to be introduced in a South African hospital. Also noted is the oncology unit with state of the art equipment and technology. To improve waiting times and way-finding, the hospital has also introduced a colour coding system.

4.8 Oversight at Orkney Clinic

The facility manager, Ms E Lesekeli informed the delegation that the clinic renders comprehensive primary health care services. The working hours for the clinic were from 7:00 in the morning to 16:00 in the afternoon on Mondays, Thursdays and Fridays. On Tuesdays and Wednesdays the clinic operated from 7:00 in the morning to 19:00 in the evenings.

Patients book appointments and their files are kept readily available for when they arrive. Those who miss their appointments are rescheduled for a day the same week they were supposed to come. The clinic has also ways of tracing defaulters. Retired nurses are employed and their line of duty is to prepare medication for the next day. This also assist in making sure that patients are attended to quickly.

The delegation had an opportunity to have a walk about at the clinic. On arrival the delegation noted that the clinic was very clean. The clinic also uses the colour coding system which is also being used at the hospital. There were different colour foot prints on the floor which the clinic used to direct patients where to go. The yellow one was for minor illnesses, blue for chronic and green for maternal and child care. This also assists those patients who cannot read. This showed to be an effective innovation as it reduced waiting times and patients know where to be attended. Patients collecting chronic medication do not sit on queues, the clinic has a system of attending to them.

In making sure that there are no drug stock outs, drug availability is checked twice a month. There is a sessional doctor who comes on Mondays, Wednesdays and Fridays to attend to patients at the clinic.

4.9 Oversight at the MDR Unit

The delegation had a walk about at the MDR Unit and was taken to a tour of the unit by Dr Ferran. Dr Ferran informed the delegation that they had two phases in the unit, phase one and two. Phase one was like a step down and was used for patients who have tested negative on their smears. Phase one was a four bedded unit. Phase two was for acute. What was notable is that the MDR unit had effective ventilation systems, both natural and mechanical ventilation.

4.10 Oversight at Witrand Physical Medicine and Rehabilitation Unit

The unit was opened in 2005. They attend to patients with spinal cord injuries. The unit is well equipped and with technology to perform urodynanics which is used to assess bladder functioning in spinal cord injured patients. There is also a well equipped gym and a hydrotherapy pool which is used by patients as part of their rehabilitation. There are beauty therapists who also attend to the patients.

4.11 Meeting with the Member of Executive Committee (MEC)

4.11.1 Officials who attended the meeting

Dr M Masike (MEC); Mr A Kyereh (Acting Head of Department); Mr A Kyereh – (Chief Financial Officer); Dr FRM Reichel (Head of Department Support); Mr BCS Redlingys (Forensic Medicine); Mr Mavundza (Chief Executive Officer); Mr PT Mokgabi (Hospital Chairperson); Mrs M Mabe (Director); Ms R Lebeko (Communication); Ms M Mabale (Protocol Officer), Ms S Mohube (Personal Assistant to the MEC); Mr KS Boikanyo (Acting CEO); Mrs MA Mohutsioa (Acting Director – Primary Health Care); Mr G Henning (Chief Director – District Health Services); Ms Wiebe-Randeree (Director – Hospital Services); Ms C Sebekesi (Chief Director); Dr U Nagpal (Deputy Director General (DDG) – NHI); Dr AKL Robinson (DDG); Ms M Seitisho (Director – MEC Office); Ms M Tlhogane (Director- Special Progammes); Ms V Moremi (JST Board Chairperson); Ms R Tshehle (HOD Support); Ms V Mbulawa (Corporate Services); Mr T Lekgethwane (Director – Communication); Dr Bogosi Moagi (Senior Clinical Manager); Mr P Mokatsona (CEO); Ms ME Rakau (Chief Director); and Mr L Kolobe (Parliamentary Liaising Officer).

4.11.2 Comments and concerns

The delegation commented on the following significant issues:

• The delegation was bothered by long waiting times observed in most health facilities visited, with some patients waiting longer than 6 hours.
• Safety and security issues were also raised as a challenge in most facilities.
• The shortage of Emergency services and long response times was raised as a concern by the delegation.
• The delegation raised a concern on private wards and the impact of these on the NHI.
• The issue of public private partnerships (PPPs) with the mining and tourism industry in the province needs to be explored.

· A report on provincial, district and local aids councils on their work and its impact should be submitted to Parliament.

4.11.3 Responses from the MEC

• Long waiting times: The office is aware of the challenge and one of the problem that leads to it is the staff shortages. The challenge is being addressed.
• Security: The tender for security went out the previous date and they are hoping this will improve security.
• Policy on private wards: The province does not have a policy on private wards.
• Shortage of EMS: in addressing the challenge the province has bought a helicopter for emergency transport.
• MDR and XDR units: The province is opening these units with the hope of closing them again. This will be done by taking care of people so that there are no defaulters.

5. Findings made by the Committee

5.1 Staff shortages were indicated in all health facilities visited. Health care workers are overburdened which further lead to long waiting times.

5.2 There is an indication of a growing population in some of the districts, this presents a challenge in terms of bed allocation in most facilities, which seems not to be meeting the growing population (for example JST hospital had 396 beds which were reduced by 60).

5.3 The budget allocated for the institutions is not enough which leads to budget influencing their plans and not the other way around.

5.4 Official transport is a major challenge as officials have to use their own personal cars for official duty.

5.5 Space shortages was identified which contributes to overcrowding wards. This was more apparent in ward 9 in Mafikeng Hospital and Boitekong Community Health Centre.

5.6 There is a lack of laundry services within some facilities and have to travel more than 200 km to get their linen laundered.

5.7 In some facilities there was underutilisation of space.

5.8 Severe shortages of linen were identified in most institutions visited.

5.9 Security concerns were identified in some of the health facilities.

5.10 Some facilities reported higher maternal mortality rates (Moses Kotane) and perinatal deaths (Lehurutshe Hospital).

5.11 There were equipment shortages in some health facilities. For example, in Moses Kotane Hospital, a mammogram machine was taken to JST Hospital and they were never given anything to replace it which makes it difficult for the hospital to screen their patients.

5.12 Equipment plans are not updated. At Mafikeng Hospital old ventilators are being used which were bought in 1997 and only three are functioning.

5.13 An X-ray machine was not properly fitted at Moses Kotane Hospital and was never used. The hospital is utilising a chest X-Ray which is a problem as patients have to stand even if they are not able to stand.

5.14 Poor infrastructure maintenance was identified in some facilities.

5.15 The issue of high teenage pregnancy was found to be a serious concern, together with a high number of requests for termination of pregnancy.

5.16 Wheelchair ramps were lacking in one of the facilities visited (Lehurutshe Hospital complex).

5.17 The delegation was also concerned that there is no health tourism, particularly around the Sun City area.

5.18 The absence of a tertiary hospital in the province presents a challenge as patients who require tertiary care have to be transported to other provinces.

6. Achievements and innovations

The following were noted by the Committee in the different health institutions visited:

6.1 All the visited public health facilities were very clean.

6.2 The delegation commended Lehurutshe Hospital for their zero maternal mortality.

6.3 The reduction of waiting times at JST Hospital was also noted.

6.4 The well equipped and functional renal unit at JST Hospital was praised by the delegation.

6.5 Stock levels of medicines and supplies were found to be managed properly in all the facilities visited.

6.6 All visited facilities have rolled-out the FDC.

6.7 Klerksdorp Tshepong Hospital has implemented some great innovations such as laparoscopic caesarean; the use of labour companions for maternity; queuing system; a burns unit; and a well equipped radiology unit.

6.8 The district is making progress in terms of implementing the NHI policy.

6.9 A well resourced MDR unit.

6.10 The delegation also commends the province for its state of the art rehabilitation facility.

7. Recommendations

The Committee recommends that the Minister of Health should ensure the following:

7.1 The province should attend to the issue of staff shortages and gaps as a matter of urgency and must report to the Committee on progress made within six months.

7.2 Hospitals should make sure that they have the relevant equipment and equipment maintenance plans are in place.

7.3 The province should adopt a needs-based approach to budgeting and meet with the hospitals to determine the actual needs of the hospitals and budget accordingly. The planning should inform the budget and not the other way round.

7.4 The National Department of Health should attend to the issue of a tertiary hospital and should assist the province in making sure that it has a tertiary hospital.

7.5 Rapid scale-up in implementing strategies and interventions to improve patient waiting times.

7.6 Urgently address high mortality rates through research into factors that contributes to mortality rates and implement evidence-based targeted interventions.

7.7 Address the issue of ambulance/patient transport as this can improve mortality rates.

7.8 Strengthen resource planning to address sufficient bed allocations in order to ensure the appropriate number of beds provided for pregnant women.

Report to be considered.