Report of the Select
Committee on Social Services on an Oversight Visit to the OR Tambo District
Municipality in the Eastern Cape, Dated 18 November 2014
1.
Ms LC Dlamini – Chairperson: Select Committee on Social Services
2.
Ms LL Zwane
3.
Mr HB Groenewald
4.
Mr M Khawula
5.
Ms TK Mampuru – Committee Whip
6.
Ms PC Mququ
7.
Ms TG Mpambo-Sibhukwana
8.
Mr DM Stock
9.
Ms MF Tlake
10. Ms L Matthys - Apology
PARLIAMENTARY OFFICIALS
1.
Ms Thabile Ketye – Content Advisor
2.
Mr Gunther Mankay – Committee Assistant
3.
Mr Mkhululi Molo – Committee Researcher
4.
Mr Sean Whiting – Committee Researcher
The Select Committee on Social Services conducted an oversight visit to
OR Tambo District Municipality, in the Eastern Cape during the week of 21-14
October 2014. This followed a decision taken during the National Council of
Province’s (NCOP) Annual Planning session held on 1-2 September 2014.
OR Tambo District Municipality is one of eight district municipalities
in the Eastern Cape. It is the biggest district[1]
in the province and comprises of King Sabatha Dalindyebo, Mhlontlo, Nyandeni,
Port St John’s and Ngquza Hill Local Municipality. The district has 168 health
care facilities (please refer to Table 1). Within the district some health care
facilities serve between 20 000 and 30 000 people while the World
Health Organisation (WHO) norm is 1:10 000 people.[2]
However, there are health care facilities that serve far less than the WHO
norm.
Table 1: Composition and number of heath care facilities in OR Tambo
District Municipality[3]
|
SUB-DISTRICTS |
HEALTH CARE FACILITIES |
|||||
|
Tertiary Hospital |
Regional Hospital |
District Hospital |
Community Health Centres |
Clinics |
Mobiles |
|
|
King Sabatha |
1 |
1 |
1 |
5 |
44 |
2 |
|
Mhlontlo |
- |
- |
3 |
2 |
25 |
2 |
|
Nyandeni |
- |
- |
4 |
3 |
46 |
5 |
|
Qaukeni |
- |
1 |
1 |
- |
20 |
2 |
|
Total |
1 |
2 |
9 |
10 |
135 |
11 |
The purpose of conducting oversight at
OR Tambo District Municipality was to assess the progress made in the
implementation of the National Health Insurance (NHI), in oneof the eleven pilot
districts in the country. The District, which is the only NHI pilot district in
the Eastern Cape, has been one of the worst performing health districts in the
country. In the South African Health Barometer it was ranked the worst district
(in the country) in the most important indicators.[4]A
study conducted by the Health Systems Trust found that OR Tambo has the worst
rate of newborn deaths – 20.8 of babies per 1000 births died in the district
compared to the 10.2 national average. OR Tambo district has been reported to
have the highest number of child deaths due to diarrhoea
(224 deaths) in the country[5] and the third highest deaths
of children under a year.In addition, almost triple the number of children
under-five died in the district’s facilities in comparison to the national
average (11.4%). In a recent survey it was reported that OR Tambo district also
had the second highest teen pregnancy rate in the country (measured by how many
births are to women under 18).4
This report provides an overview of the
areas the oversight focused on, highlights the findings from the sites that
were visited, and challenges experienced at the health care facilities. Based
on these, recommendations and issues for follow-up were identified and made.
The NHI is a form of mandatory insurance that supports a system of
universal health care coverage where every citizen (and
legal long-term residents)
in South Africa is covered.[6]
This innovation is aimed at addressing past and present imbalances on access of
health care services in the country. The core strategy behind this health care
system is ensuring an efficient, effective and quality driven health service
delivery through the Primary Health Care (PHC) approach - thus a strong focus
on health promotion and prevention services at the community and household
level.
The objectives of the NHI are:[7]
Broadly, the
following NHI Grant outcomes[8]
informed the site visits:
In terms of assessing progress in the implementation of the NHI in the
pilot district, the Select Committee focused on the following imperatives for
NHI:
a)
Infrastructure Development and Management
·
Accessibility
of health care facilities
·
Physical infrastructure of
the health care facilities (building, waiting room/reception, etc.).
·
Availability of health care
resources, for example, an ambulance; beds in a hospital.
·
What infrastructure
programmes are being implemented? If there are any, what is the status of
those? When were they started? When are they meant to be finalised?
b)
Human Resource Planning, Development and Management
·
What is the staff complement
– family physicians, nurses, specialists, etc?
·
What training has the
staff/capacity building programme have the staff received/attended? When did it
take place?
·
Staff complement by category
and gender
· What
is the nurse-patient ratio?
· Are
performance agreements in place?
· Administration
issues including a good filing system and filling of vacancies.
c)
Quality of Health Services
·
Cleanliness
of health care facilities,
·
Safety
and security of staff and patients,
·
Attitude
of staff towards patients,
·
Infection
control,
·
Long
queues,
·
Drug
stock-outs/Availability of medicines.
d)
Re-engineering of the Primary Health Care System (PHC) within three streams (i.e. Schools Health
Programme, Municipal Ward-Based Primary Healthcare Agents, and District
Specialist Health Teams)
·
Do these programmes and/or
teams exist in the district? What services do they provide? How often do the
school-based/ward-based outreach/district health teams visit
schools/communities?
e)
Contracting
of General Practitioners (GPs) and other Health Professionals, to work in
public facilities
·
Does the district have any
partnerships with the private sector? What is the nature of these?
f)
Strengthening
hospital performance
·
What are the mechanisms of improving provision of health care services
in the facility (hospital/clinic)?
Oversight of this NHI
pilot district entailed meeting with relevant role-players and stakeholders
(within the OR Tambo District and the Province), as well as undertaking site
visits at five health care facilities, viz.:
The
mode of information sharing was largely through power-point presentations led
by hospital Chief Executive Officers (CEOs). These were followed by discussions
where the Members of Parliament (MPs) asked questions to explore and probe on
issues raised in the presentations. In addition to those engagements, the
delegation walked around the health care facilities. Information presented in
this report therefore comes from the information collected from presentations
and observations.
Nelson Mandela Academic Hospital (NMAH) is a teaching hospital within
the Mthatha hospital complex. The NMAH has good infrastructure and the complex
is easily accessible to the community. However the Mthatha “Regional” Hospital
has old dilapidated buildings which require reconstruction.
Mthatha General Hospital is being developed into a regional hospital.
The hospital complex will include Bedford Orthopaedic Hospital, which will be
converted into a ward for NMAH. NMAH is being developed into a general
hospital. In future, these two hospitals will have (two) separate budgets. A
CEO has recently been appointed for the Mthatha “Regional” Hospital. However,
the development of organograms (for the two health care facilities) is still
underway. The process of re-developing the health care facility/complex started
in August but still use the same structures which are located in Mthatha “Regional”
Hospital.
Within the complex, there is a one-stop centre for ex-miners. The health
care facility also offers an eye camp to decrease cataract cases, and NMAH has
a Specialist Department with new accreditations.
The health care facility uses a manual filing system.
It was reported that poor/negative attitude of clinical staff remains a
challenge. At times it is deliberate, but at times it is due to stressful
working conditions.
There is a high volume of trauma patients which leads to long waiting
times. However, the health care facility is expecting private orthopaedic
surgeons to be contracted. In addition, on a seasonal basis the health care
facility experiences a high volume of complicated circumcision cases.
There are budgetary constraints which results in some critical posts not
being filled. The health care facility has a shortage of Pharmacists (among
others). According to the NMAH CEO, currently there is no budget for NHI
readiness although OR Tambo is a pilot district.
The clinical infrastructure and equipment is inadequate, particularly
taking into account the rationalizing of the complex. The NMAH has 588 beds but
require 800 in total. There is no proper oncology unit thus only chemotherapy
is offered and patients are transferred to East London. The hospital also
required a nephrology and renal unit. There is no tuberculosis (TB) hospital in
the area which means that those patients must be transferred as per the need.
Children’s beds are insufficient, and there is a shortage of offices and
lecture rooms. It was also reported that Mthatha “Regional” Hospital
experiences water challenges.
Patients travel long distances to reach the health care facility, and
there is no in-house accommodation for them. In the interim there is an attempt
to acquire a park home for mothers who are waiting for their children who have
been admitted. To minimise long waiting times, the health care facility is open
every day including on weekends and public holidays.
Filling of critical posts should be prioritised. There should be a strengthened
outreach programme in the community with a focus on primary health care and
provision of quality care. This would also minimise long waiting times in the
Out Patient Department.
The provincial department should look into fast-tracking the
rationalization process and development of organograms. This should be done in
line with budget allocations.
This is an old hospital which was started in 1893 by Missionaries. This
facility had a mental health clinic which was closed in April 2013.
The hospital has a good security system. Outside the hospital there are (water)
reservoirs which require fencing.
The CEO indicated that the logistical information system (LOGIS) was
installed at the hospital to fast-track procurement services.
There is a challenge in the reading and use of the allocated budget.
According to the report provided by the CEO, over 80% (R86 644 334.00)
of the total budget (R100 401 971.00) has been allocated for
compensation of employees; and the remainder (R12 898 975.00) on
goods and services. In addition, an overall 64% has already been spent.[9]
The hospital is not easily accessible, and there is a need for transport
facilities. In addition, the hospital is experiencing a high vacancy rate
exacerbated by the myth of non-payment of pension funds. According to the CEO,
some professional nurses leave the health care facility to become Ward-Based
Team Leaders. Generally there is a poor response to adverts, especially of
clinical staff – people do not see an incentive to work in the area.
Building and improvement of the physical infrastructure is required,
especially for the TB patients. Staff accommodation remains a challenge.
Doctors are accommodated in four modular structures. Mental health patients are
nursed in a general ward – they are observed over 72 hours and then referred to
the nearest mental health carefacility. The Out-Patient Department (OPD) is
congested and requires an extension. There is no maternity waiting home which
is a requirement in terms of Campaign for Accelerated Reduction of Maternal Mortality in Africa (CARMMA). There are no isolation wards to control/manage
infection. There are no dryer machines in the laundry room, thus linen is hung
outside to dry.In terms of staff, accommodation is required. However, the CEO
indicated that accommodation and a resource centre will be built by the Walter
Sisulu University Foundation, and construction will start in early November
2014.
Currently, there is no space for the safe-keeping of patient records
which may lead to misfiling and loss of records.
The hospital experiences drug stock-outs as the medical depot does not
always supply all the ordered medication. In addition, servicing and procuring
of medical equipment is a challenge.
On a seasonal basis (mainly June and December) the hospital experiences
an increase of septic initiates.
The provincial department should ensure that there is a maternity home
in the hospital, and investigate how the hospital laundry services could be
improved. In addition, a progress report on these including building and
upgrading plans and implementation thereof should be provided to the Select
Committee.
The district should strengthen primary health care (PHC) awareness and
outreach in the communities.
The hospital management should be capacitated and supported in terms of
budgeting.
The issue of vacancies should be noted and addressed by the provincial
department.
This is an old mission hospital (built in 1927) which requires
redevelopment and upgrading (as it has never been upgraded since) – the
infrastructure is dilapidated. The nurses are accommodated in caravans behind
the hospital. The wards are poorly ventilated. However, COEGA Development Corporation
has been commissioned to re-build the hospital as part of the national Hospital
Revitalisation Programme within 3 years. The construction is on Phase 2 (earthworks)[10].
Phase 1 has been integrated with Phase 2. Phase 3 includes building of staff accommodation
and Phase 4 includes building the hospital complex.
In paper, the hospital has 150 usable beds with 177 that are approved.
However in reality only 100 beds are usable. The new hospital will then only
have 100 beds.
The hospital is not easily accessible. Lilitha Nursing College, which is
located within the same hospital complex, belongs in a different programme and
thus has a separate organogram and budget. The hospital waiting time is an
average of 4 to 5 hours (this is written on the Reception’s Notice Board).The
hospital has a poor filing system.
The CEO indicated that there is a Hospital Board which has been
existence for the past 3 years. He also indicated that in terms of mortuary
services, which are available 24 hours a day, daily; they have a Mortuary
Attendant who is relieved by Porters when the need arises.
The current CEO only started at the hospital in April 2014. The hospital
has 225 employees and a vacancy rate of 36%. The high turnover started recently
(about four months ago) due to myths about pension pay-outs.
The hospital has an over-expenditure of about 8% on compensation of
employees (COE) due to an accrual of HR benefits from the previous financial
year. The CEO reported that the COE expenditure is at 58%, with about 53% of
the overall budget having spent.
The hospital’s organogram is outdated and does not take into account the
current needs of the institution. The hospital relies on the personnel and
salary (Persal)system in terms of its staff establishment. There is an Acting
Clinical Manager and an Acting Quality Assurance Manager. The post was last
filled in 2009. This post is being re-advertised by the provincial Department.
In 2010, the post was advertised but there no responses. Following that
head-hunting took place and a candidate was identified, however the candidate
received an offer at the NMAH. Currently there is no Radiographer; and the
hospital uses a courier service for laboratory services.
Internet connectivity is functional in the hospital however the hospital
receives limited bundles. The Basic Accounting System (BAS) is working well but
there is no LOGIS.
Between the two quarters of 2014, the case fatality
rate has increased (from 8.6% to 11%), case fatality rate for surgery
separations increased (from 2.4% to 8%) and perinatal mortality rate increased
from 3% to 8.5%. The main causes of the fatality rates are diarrhoea, pneumonia
and malnutrition for the children under 5 years. On a positive note, cervical
cancer screening among women 30 years older took place in the second quarter.
There is only one ambulance that is accessible to the hospital, which is
only used for maternity cases. When there are patients who need to be referred
to another hospital, they are transported with a van.
There are no isolation wards/units in the hospital. This creates a
challenge when there are patients suffering from Tuberculosis (TB). This
includes Multi-Drug Resistant (MDR) and Extreme-Drug Resistant (XDR) TB
patients which the hospital is not well-equipped to assist (and does not admit)
There is no TB ward, and thus patients are nursed in a partially open are with
no ablution facilities.
The provincial department should provide the Select Committee with
quarterly reports on progress of the hospital construction project; as well as
the project plan which shows the integration of Phases 1 and 2.
The provincial and district departments should fast-track installation
of LOGIS at the hospital, and acquisition of Emergency Medical Services (EMS)
for the hospital so that patients are properly serviced and transported.
Awareness-raising and advocacy should be done in the district so that health
staff are sensitised about the myths of non-payment of pension funds.
The provincial department should find an interim workable solution for
the treatment of TB patients in the hospital.
Filling of critical posts should be prioritised by the provincial
department.
There are no visible health facilities in the area (except for this
hospital). The physical infrastructure of the hospital needs upgrading and the
staff accommodations needs to be built as they stay in shacks. There was also an
indication of electrical power challenges (in the hospital). This is another
hospital that has been included in the national Hospital Revitalisation
Programme.
The hospital is experiencing a high nurse vacancy rate at the hospital
(more recently) due to myths about loss of pension funds. In addition, the post
of Hospital CEO is vacant. Dental services and abortion services are not
provided at the hospital. Patients were seen wearing gowns written TB at the
back.
There is no proper fencing at the back of the hospital although there are
security guards at the gate.
There was a community picket outside of the hospital gate on the day of
the site visit. Members of the community raised a number of issues which refer
to the staff attitude towards patients, availability of medication and food,
infrastructure and facilities, and emergency medical services.
Accessibility to the hospital may be a challenge considering that there
are no available ambulances and employed drivers.
The Acting CEO indicated that internet connectivity is functional in the
hospital however the BAS and Persal systems are not functional due to problems
with the data line. As a result of this, the hospital staff have to travel to
another health care facility to access those systems. This also applies to
accessing medication when there are stock-outs.
The hospital is one of many health care facilities in the province that
have an outdated organisational structure, and thus health care facilities rely
on a Persal staff establishment. According to the Persal data, there are 209
employees in the hospital with a 10.5% vacancy rate. This includes one Clinical
Manager and three additional doctors, with one being a sessional doctor.
The term of the Hospital Board ended in September, thus there is no
Board currently. However,according to the District Health Systems Manager a
process is underway at a political level to appoint Board Members.
It was reported that the mortuary is closed over the weekends. This is
following an incident that was found of porters taking bodies of the deceased (from
the village) and keeping them in the mortuary without the knowledge of hospital
management.
According to the Acting CEO patients receive a balanced diet but
sometimes run out of stock and then feed patients what is available (usually
soup, pap and potatoes). At times this is due to slow payment of service
providers. The Chief Financial Officer (CFO)from the provincial department explained
that in terms of supply chain management (SCM), payment is made within 30 days
in the province. However there may be delays when there rendering of services
happens outside the official order.
The Clinical Manager indicated that nurses provide PHC after hours, and
a doctor that is working after hours only provides support.
The CFO indicated that construction of a new hospital will be taking
place in the not so distant future, and the provincial office will provide the
Select Committee with a project plan in this regard. With the new building, the
number of beds would be reduced due to the rate of bed use – from 134 to 76. In
addition, the Select Committee will be provided with a quarterly update on the
building of the new hospital.
The organogram and thus staff functionality need to
be reviewed.
Overall, management needs to be strengthened.
Management training should be offered to the hospital managers.
There should be supervision at the mortuary. The
hospital management should revisit the policy of operating hours of the
mortuary.
Shift hours for doctors working at the hospital
should be considered, or the use of on-call doctors should be better managed
and facilitated.
The Select Committee visited five health care facilities at OR Tambo
district, during this oversight. The facilities were visited with various
stakeholders and role-players, including Members of Parliament from the Eastern
Cape Provincial Legislature, provincial and district officials from the
Department of Health.
This proved to be a fruitful exercise as it enabled the stakeholders and
role-players to understand the status of health care service provision in the
NHI pilot district and also thoroughly engage on observations made and reported
matters.
In the main, the following are crucial in strengthening the OR Tambo
district health system:
Following this undertaking, the Select Committee on Social Services will
(continue to) undertake oversight on the health care facilities visited on
21-24 October 2014.
Report to be considered
[1]The total population is estimated to be at
1 364 941. Census 2011. Statistics South Africa.
[2] World Health Statistics: Indicator Compendium. 2012. World Health
Organization.
[3]Information received from the Department of Health
Eastern Cape.
[4]District Health Barometer
2011/12. Health
Systems Trust.
[5]District Health Barometer 2013/14.Health Systems Trust..
[6]National Health Insurance in South Africa,
Policy (Green) Paper. 2011.Department of Health.
[7] Matsoso P. National Health Insurance: The first 18 months. South
African Medical Journal, 2013, 103 (3): 156-158. National Health Insurance: The
first 18 months.
[8] Health-e. 2013. Retrieved from: http://www.health-e.org.za/2013/11/25/national-health-insurance-pilot-district-business-plans/.
[9]The figures provided do not add up.
[10]This is inclusive of the repairing of old
water pipes and upgrading of electricity.