PORTFOLIO COMMITTEE ON HEALTH
06 October 2009 
Discussion with the South African Nursing Council & Department of Health on challenges faced by the Council

Chairperson: Mr B Goqwana (ANC) 

Audio Recording 
Discussion with the South African Nursing Council & Department of Health on challenges faced by the Council

SUMMARY
The Portfolio Committee on Health met with the South African Nursing Council and the Department of Health in order to get a better understanding of the challenges facing the Council in delivering on their mandate. Particular emphasis was placed on addressing the poor quality and quantity of nurses in South Africa. The decision to meet with the Department was taken at a previous meeting with the Council, during which the major challenges were outlined, including conflicting regulations; shortage of adequate funding and reduced member numbers. 

The Committee perceived both the quantity and quality of nurses in South Africa to be lacking and urged that the matter was addressed as a matter of urgency.  The Committee required the Department to develop better working relationships between provincial and national departments.  The Provincial Departments of Health was required to escalate efforts to address the issue.  The Committee felt that the Department failed to discipline provinces when regulatory standards were not met.

Members were concerned over the changing disease profile in South Africa, which increased the challenges faced by the nursing profession.  The issue of cleanliness in hospitals remained an ongoing concern.  The Council was however legally and constitutionally prevented from disciplining under-performing hospital managers.  Members asked questions about the retention of qualified nurses in the public sector and the quality of training provided.  Questions were asked about the action taken against unregistered nursing schools and the role played by the SETA.

MINUTES
Briefing by the South African Nursing Council
Ms N Makhanya (Chairperson of the South African Nursing Council) summarised the key challenges faced by the SANC. The Council was established in terms of the Nursing Act of 2005 but none of the elements of this Act were implemented before 2008. As the Act provided only a broad framework in terms of implementation, the Council’s first challenge was to develop the necessary regulatory implementation, which would enable the Council to successfully implement its mandate. Although it was, in terms of the Act, the responsibility of the Minister of Health to develop regulations, the Council was obliged to work together with the Department towards finalising these regulations. 

The Council was responsible for the regulation of nursing education and nursing practise. One of the reasons the Act had to be revised was for it to hold more relevance in terms of South Africa’s broader transformation agenda (i.e. changes in disease profile and needs of its citizens as well as its socio-political development). The previous Council initiated a process that addressed the quality of service by looking at the practise component of nursing in order to identify which practices were critically required to meet the current demands for healthcare. This process was guided by the White Paper on transformation of health services, which defined the country’s new needs in terms of legislation. One of the weaknesses in the previous Council’s Scope of Practice was that it looked into the tasks that nurses had to carry out. However, because there were a number of healthcare facilities that were being manned by people who lacked sufficient training, the present Council looked into defining a competency framework. This competency framework not only laid out clear competencies necessary in order to be recognised as a nurse but also led to the development of new scopes of practise, which in turn led to new educational requirements for qualification as a nurse. 

The Council’s oversight role related to the accreditation of health facilities as well as all aspects of nurses’ education (approval of curricula, approval of clinical learning sites and approval of learning sites such as Colleges and Universities). Since July 2008, the Council had developed 12 regulations with priority given to practise and education. In education, the Council had, together with the Department of Health, been in the process of developing a regulation that would enable it to accredit institutions differently. Until this regulation was passed, however, it could not implement this new accreditation system. The main challenge faced by the present Council concerning matters related to practise, was the fact that it was made up of less members.  Of the current total of 25 members, 14 were professional nurses.  The previous Council had 36 members. The reduced number of members prevented the Council from functioning at an optimal level.

The main challenge related to education was the fact that, although the Council had been very proactive in defining educational requirements to meet the new Scope of Practise, there had been developments in the mainstream education landscape, particularly around the Council for Higher Education (CHE) and South African Qualifications Authority (SAQA) which had implications on the qualifications the Council had been developing. As a result the Council had to review its qualifications so as to be in line with the new CHE and SAQA requirements. 

Discussion
The Chairperson recalled that, in an earlier presentation, the Council had said that there were conflicting laws that limited the Council in the delivery of its mandate. The Council also said that more would be achieved if there were more members. The issue of funding was also raised. The Council felt that the limited funding received from the Department limited the ability to deliver on the mandate. He asked the Department representatives to provide further clarity on these issues. 

Dr. Percy Mahlathi (Deputy Director-General, Department of Health) said that although the Department of Education had the sole mandate for Higher Education Training in South Africa, it had to work together with all other sectors in order to fulfil its mandate. A challenge that the Department of Health faced was that bodies which fell under the Department of Education had their own qualification frameworks, which were in conflict with one another (such as the CHE and SAQA qualification frameworks). Another challenge the Department faced was the Department of Education’s re-working of the rules around the Education and Training quality assurance bodies as this effectively removed this responsibility from the health statutory bodies. The Department had engaged all the relevant stakeholders in finding ways to address this issue. These conflicts arose as a result of each sector refining its programmes with a view towards improving its functionality and were, therefore, unintentional. This issue was, however, a legislative issue.

Mr M Waters (DA) asked how the Department envisaged the Council fulfilling its role without proper funding.

Dr. Mahlathi replied that Colleges received funding from the provinces in which they were located. 

Mr D Kganare (COPE) asked how the Health and Welfare SETA was being engaged in both financial terms as well as in the training of nurses. He asked if there was any strategy to make access to the nursing profession easier, thereby increasing the number of nurses.

Ms S Mchunu (Acting Registrar and Council CEO) answered that SETAs were the responsibility of the Department of Labour and were subject to the Skills Development Act. The financial contribution of the SETA was in the form of learnerships. The beneficiaries of these learnerships were selected in accordance with an agreement between the SETA and service providers (such as hospitals who were linked to nursing schools). Problems arose when some private nursing schools saw this as an opportunity for financial gain even though they lacked resources. Assistance from the Health and Welfare SETA therefore had to go hand-in-hand with credentialing bodies. 

Dr. Mahlathi explained that the Department wished to encourage public nursing colleges to increase the number of trainee nurses. A number of challenges were brought to light as a result of a 2006 audit of colleges by the Department, many of which related to poor infrastructure. Other challenges were found around the issue of the amalgamation of educational institutions. Problems arose as a result of some Universities requiring a basic qualification in order to qualify as a lecturer when not all lecturers at colleges possessed the necessary qualifications. The other issue was that of the financing of students. There was, as yet, no uniformity across the country with regards to how students were financed to study. Some provinces, like KwaZulu-Natal, were providing stipends. Problems with stipends arose when students saw these stipends as a salary, claimed to be employed and felt entitled to the benefits enjoyed by employees. Some provinces, such as the Western Cape, were providing students with bursaries. Problems arose when recipients of these bursaries viewed themselves as students and not workers. This affected their practical training. The Department was working towards getting the provinces to adopt a more uniform system to address this issue. The Department had approached National Treasury to aid in the revamp of nursing colleges. To this end, funds were made available for a study to be conducted in order to determine the needs around this issue. To increase the number of nurses being trained, the cost of training nurses had to be reviewed. Another consideration was whether the quality of nurses produced through Universities differed from those produced by colleges. The Department had developed a mid-level worker policy that debated around the issue of task-shifting and task-management. Nurses had to be able to deal with challenges that arose from medical errors. Access must also relate to the quality of secondary education. Entrance requirements to study nursing should also be stricter to ensure a better quality of nurse.

The Chairperson asked what was being done to address corruption at learning institutions. 

Dr. Mahlathi responded that this was a serious problem and that the only way to effectively fight this was through people reporting such incidences. Cases that had been reported previously had been followed up. 

Ms Makhanya added that corruption was not only about access but needed to be looked at from a broader perspective. An integrated strategy should be developed when addressing this issue. There were many factors that contributed towards the flourishing of nursing colleges and corruption. Nurses were recruited into these colleges in order train in home-based care - a direct result of having to cope with the demands of HIV/AIDS. Nurses also chose to be within this system rather than outside of it as a result of the limited opportunities within the Public Sector where recruitment processes were different. The Council could not prevent the opening of nursing schools but could instead look at applying accreditation criteria. Deregistering a non-compliant school was also a legislative process.

Ms T Kenye asked what the motivation was behind the reduction of SANC member numbers.

Dr. Mathlathi answered that this issue was first looked at with the establishment of a committee which looked at the transformation of Statutory Councils. It was decided, through this committee, to both streamline the South African Nursing Council as well as bring in expertise that did not exist in the Council at that time and also fell outside the nursing profession (e.g. law, finance etc). The reason for this decision was due to the challenge the previous Council faced with regards to representatives of communities having very little grasp of the oversight role played by statutory bodies. Another reason for this decision was to ensure that the majority of Council members were qualified nurses. Although it was cheaper to fund a body made up of fewer members, it was not the Department’s duty to fund the Council as all statutory bodies were dependent on membership fees for funding. This was done so as to ensure semi-independence from Government as their primary role was the protection of the public good. If the Council felt that their declining member numbers were affecting their work, the Minister would be willing to engage with them on that issue. 

The Chairperson asked what was being done to increase the number of nurses in rural areas. 

Dr. Mahlathi replied that there was a general influx of people towards urban areas. The Rural Allowance was being revised. Other factors, such as accommodation and infrastructure, had to be taken into consideration. 

Ms E More (DA) asked whether the Department had a plan in place to retain nurses.  She asked who was responsible for accrediting, monitoring and evaluating the hospitals at which nurses completed their in-service training.  She wanted to know what was being done about fly-by-night nursing schools, especially regarding those students who had studied at these schools in the belief that the training provided was legitimate. She asked what was being done to address the issue of nurses who were University-trained and who refused to do more menial work in hospitals.

Dr. Mahlathi answered that the Department had undertaken an agreement with organised labour that, in order for a nurse to qualify for OSD remuneration, s/he had to have a qualification that was registered with the Council. Although the Department strove to ensure that provinces ensured that managers and supervisors ran their healthcare facilities effectively, it could not deal with this issue as the primary employer was the province. Although the issue of unregistered schools fell under the mandate of the Council, the Department had acted together with the Council in dealing with such institutions. Concerning the matter of the behaviour of University-trained nurses, he pointed out that not all such trained nurses behaved in this manner. This was a societal issue.

Ms. Mchunu added that, according the Nursing Act of 2005, the Council was obliged to inspect health facilities about which complaints were laid, whether these facilities had students or not. Because it was not possible for the Council to execute inspections on a more frequent basis, it was important that the provinces had their own internal quality control mechanisms in place.

Mr. Kganare asked whether the closing of the nursing colleges was done too soon or without a thought to the consequences of the decision. He asked what impact the requirement that a professional nurse had to have a degree had on the effective provision of health services.
 
Dr. Mahlathi responded that very few nursing colleges were closed down as many were amalgamated with other institutions and most of those that were closed down were subsequently re-opened. Although the amount of University-trained nurses was negligible when compared to colleges, they played an important role in terms of research and innovation in Health Sciences.

Ms. Makhanya added that the nursing profession needed people who were multi-skilled and could think critically and these needs were generally better met by nurses who were University-trained.

Mr. Waters asked who oversaw the process of improvement of quality education and training. As members could only contribute a certain amount in membership fees, how would funding levels be improved.  He asked where the Department saw private education institutions in helping to alleviate the backlog of nurses.  He asked if the potential scrapping of labour brokering affected the shortage of nurses.

Dr. Mahlathi replied that some private institutions placed nurses in public facilities to complete their practical training. Most of these nurses unfortunately returned to the private sector. The issue of labour brokering was a political issue he did not wish to address.

Ms. Kenye asked what was being done to ensure that, upon qualification, a nurse carried both practical and theoretical knowledge.

Dr. Mahlathi responded that nurses who studied at Universities also completed practical training. It was, however, very difficult to monitor the retention of knowledge.

Mr. Kganare asked what the private sector was contributing towards ensuring that public sector nurses were adequately trained. There needed to be a clearer distinction between the roles of managers and shop stewards as confusion around this issue added to the lack of discipline in hospitals.  He asked what happened to unregistered colleges when they were found to be non-compliant.  He asked if the Department had a process whereby dates were set for the achievement and/or evaluation of objectives that were set.  He asked what the role of Public Works was when infrastructural improvements were required.
 
Ms. Mchunu answered that, although the bigger private hospital groups trained nurses to meet their own needs, these hospitals had their own health facilities in which students were placed for clinical practical training sessions. Individual private nursing schools, however, did not have such facilities. Although a contribution towards alleviating the backlog was made, the quality of education received here was questionable. The Department should consider utilising its clinical facilities to improve the quality of nurses’ skills. When reported, unregistered nursing schools were dealt with by the Council. These schools were closed down and in certain cases; the persons responsible for running these schools were prosecuted.

Dr. Mahlathi added that managers should be taken to task when they handed their duties over to shop stewards. Once a report on the issue of infrastructure maintenance and repairs had been completed, the Department had to further engage with National Treasury as well as with the Department of Public Works on the matter.

The meeting was adjourned.