ATC110309: Report oversight visit to the Free State
Report of the Portfolio Committee on Health on an oversight visit to the Free State, dated 9 March 2011
The Portfolio Committee on Health having undertaken an oversight visit to the Free State from 3 – 6 August 2010 reports as follows:
1. EXECUTIVE SUMMARY
HIV/AIDS and Tuberculosis have played a major role in increasing the mortality rate of mothers and children and still continue to account for a significant burden of diseases in South Africa.
As its oversight role, the committee therefore decided to conduct oversight at various public health facilities in the Free State. The aim was to assess their infection prevention and control strategies, management of the HIV, and the control of MDR and XDR Tuberculosis.
This report presents a summary of information on the various health facilities, achievements and challenges they are facing. From the collected information, it draws conclusions on the challenges faced in the health system of the Free State province.
The Portfolio Committee on Health conducted oversight over different health facilities in the Free State province during the period 3 to 6 August 2010. The aim of the visit was to conduct an oversight function to assess the quality of health service delivery in relation to HIV/AIDS and infection control.
The objectives of the oversight visit were to:
- Assess if the new HIV/AIDS policies and strategies were implemented as announced by the President on the World AIDS Day (1 December 2009);
- Assess infection control strategies and the quality of health services;
- Gain insights on the functioning of the district and tertiary health system in the Free State;
- Observe facilities for child-birth in line with the UN Millennium Development Goals (MDGs) 4 and 5, which are to reduce infant mortality and maternal mortality respectively; and
- Assess the functioning of the Medical Depot.
Dr MB Goqwana – (Committee Chairperson and the leader of delegation, ANC)
Ms MC Dube - (ANC)
Ms TE Kenye – (ANC)
Dr A Luthuli – (ANC)
Ms Segale Diswai – (ANC)
Mr E Sulliman – (ANC)
Ms E More – (DA)
Mr M Waters – (DA)
Mr DA Kganare (COPE)
Ms HS Msweli – (IFP)
Ms V Majalamba (Committee Secretary)
Mr Zubair Rahim (Committee Researcher)
Ms S Bawa (Committee Assistant)
5. VISITED HOSPITALS
- Elizabeth Ross,
- Mofumahadi Manapo Mopeli,
- Pelonomi, and
6. ELIZABETH ROSS HOSPITAL
DELEGATION FROM THE HOSPITAL
Rampane S Moeketsi: Clinical Manager/Acting CEO
Mr NA Mashinini: Administrative Assistant Manager
Mr MC Lerore: Administrative Assistant (Nursing)
Elizabeth Ross District Hospital is located at Maluti-A-Phofung municipality in the rural area of Qwaqwa. The bed occupancy rate stood at 72%, and the average length of stay was 4 days. The cost per PDE was R1230.
The hospital has 110 usable beds, and is linked to 32 clinics through a referral system. The hospital was also responsible for the outreach services to these clinics and in different disciplines. The hospital refers patients to Mofumahadi Manapo Mopeli Regional Hospital for higher level of treatment.
The hospital renders medical, surgical, paediatrics, maternity, frail care, rehabilitation, social work, oral health, radiographic, mental health, domestic violence, clinic and emergency services. Elizabeth Ross is the only hospital in the Free State Province that renders reproductive health/termination of Pregnancy services to the neighbouring Provinces.
With regard to HIV/AIDS the hospital has started with counselling and testing and the initiation is done at the ARV sites. Patients who were initiated on Highly Active Anti-Retroviral Therapy (HAART) presented themselves at the hospital without treatment, and the pharmacists arranged with the sites to provide treatment. The Prevention of Mother to Child Transmission (PMTCT) is rendered in partnership with Elizabeth, Glaser, Paediatric Aids Foundation (EGPAF).
There was a dedicated infection control personnel that was overseeing the infection control of the hospital. Swabs for culture were also taken once a year.
6.1 CHALLENGES FACED BY THE HOSPITAL
v Replacement of fleet,
v Power Supply
v Equipment shortages
v 46% of vacancy rate,
v Accommodation for Health Professionals at the hospital,
v Slow Hospital revitalisation,
v Geographical location of the hospital, and
v There is no proper Mental Health care.
v Medical Depot not supplying on time
6.2 WALK ABOUT AT THE HOSPITAL
6.2.1 MATERNITY WARD
On the day of the visit, there were only three professional nurses on duty and they highlighted that they were short staffed and sometimes nurses have to attend meetings and also escort patients to Manapo Hospitalwhen a need arises.
The nurse in charge informed the committee that they were handling more than 300 deliveries a month. They had 207 and 217 deliveries in June and July 2010 respectively.
The sister in charge also informed the committee that they needed ambulances with mobile incubators as it was very difficult for them to transport pre-term babies from Elizabeth Ross to Manapo hospitals.
The other challenge that was highlighted was the lack of resources and sometimes they had to use the ordinary sellotape for an IV line.
6.2.2 DELIVERY ROOM
The delivery room was not well equipped as there were no medical consumables like gloves and the hospital had to get assistance from other institutions.
6.2.3 POSTNATAL WARD
The postnatal ward has six beds and it was overcrowded on the day of the visit.
6.2.4 FEMALE WARD
The female ward has 24 beds. There were only four professional nurses responsible for the ward. Two professional nurses worked on a day shift and two on a night shift. When the sister in charge was asked of how they were coping with the work load, she informed the committee that sometimes they were assisted by nurses from other wards and were also using nurses provided by nursing agencies.
6.2.5 MALE WARD
The male ward has 24 beds. They admit and/or accommodate both medical and surgical patients. There were only two professional nurses on night duty and five on day duty. The committee noticed that the male ward was under-staffed.
6.2.6 STEP DOWN AND STEP UP WARD
There were six beds for females and six for males in the ward.
The sister-in charge of the ward welcomed the committee. She came across as very passionate about her work. She informed the committee that the ward takes care of the critical ill patients and those awaiting social workers and had no place to go to. She also told the committee that patients’ condition improved and continued leaving their normal lives.
The ward was short staffed and they made use of volunteers. Before working in the ward, volunteers were trained first for 59 days.
7. MOFUMAHADI MANAPO MOPELI HOSPITAL
DELEGATION FROM THE HOSPITAL
- Ms Mohau Flory Kobeli: Quality Coordinator
- Dr Nandy Akweyo: Family Physician
- Mr Malinga Busisiwe Linah: Infection Control
- Ms MA Mtombeni: Acting Head of Nursing Services
- Ms Emly Mahladi Radebe: Assistant Manager
- Mr Seati Jeremiah Moloi: Clinical Manager
- Dr BD Manolo: Medical Officer
- Mr M Marais: Pharmaceutical Services
- Mr Tsepo Mositoane: TB and HIV Coordinator
- Ms T Gloria Mpelwana: Infection Prevention and Control Coordinator
Mofumahadi Manapo Mopeli Hospital Regional Hospital was opened in 1987. The hospital was commissioned for 300 beds but only has 270 functional beds. The hospital services a catchment area with a population of about 500 000 from the Manapo and Phumelela District Municipalities. It also serves Elizabeth Ross, Thebe and Phumelela district hospitals. District services provided at the hospital were psychiatric, CT scan and optometry. Outreach services are urology, child psychiatry, dermatology, genetics and orthopaedics.
The clinical support provided by the hospital is ophthalmology clinic, renal unit, pharmacy, clinical psychology, speech and audiology, occupational therapy, physiotherapy, social work and dietetics services.
The institution is the nerve centre and coordinates activities for the district. It also serves as a specialist clinic for ARV’s. There is dedicated staff for HIV Counselling and Testing (HCT who comprised of 2 professional nurses, 1 lay councillor and 1 data capture for the district. The district targeted 241 577 people for HIV testing and only tested 3226 people. The institutional target was 3660 people but only managed to test 424 persons. In efforts to meet the target, the hospital has made the following plans:
v Specialist clinic for catchment areas
v HCT to be done in OPD and in the wards
v Daily HCT information session in OPD and in the clinic
v Form part of district plan for campaign and social mobilisation and out reach
v Proposed partnership with the Department of Social Development for counselling.
7.1 TUBERCULOSIS (TB) MANAGEMENT
The hospital followed the national and provincial policy guidelines on the management of TB. There was a dedicated HIV and TB coordinator for the institution. Patients are screened for TB and there were dedicated cubicles for TB patients. The co-ordinator conducted training for staff. The in-house laboratory enhanced diagnosis. MDR and XDR cases were referred to specialised hospital in Thaba Nchu.
In addressing infection control, the hospital was follows the national and the provincial policy guidelines. There is a dedicated infection control officer who also is a member of the institutional risk and quality assurance management committee. There is an infection control program for the institution and an infection control committee which represented all units.
Staff is trained on infection control. There is monitoring and evaluation of infection control practices. A validation of monthly audit is done. Spot checks for compliance are undertaken randomly.
7.2 THE INSTITUTION HAS SET THE FOLLOWING PRIORITIES:
v Provision of 9 basic clinical disciplines,
v Recruitment and retention of health professional,
v CHOSASA accreditation,
v Compliance with ministerial priorities,
v Meet the HCT target, and
v Accelerated maintence program.
7.3 MAJOR INFRASTRUCTURAL PRIORITY PROJECTS FOR 2010 WERE AS FOLLOWS:
v Upgrading of lifts starting in August 2010,
v Procurement and replacement of medical equipment which is budgeted for R5 million,
v Erection of the fence,
v Replacement of emergency generators, and
v Replacement of steam water pipes.
7.4 CHALLENGES FACED BY THE HOSPITAL
v Provision of a 24 hour medical coverage in some disciplines,
v Recruitment and retention of medical officers in the catchment areas,
v Finalisation of OSD for Doctors and nurses,
v The infrastructure has depreciated, and
v Budget limitations which made it difficult for the hospital to deliver on its mandate.
v Medical Depot not supplying on time
7.5 WALK ABOUT AT THE HOSPITAL
7.5.1 MALE SURGICAL WARD
Not all beds were utilised in the male surgical ward on the day of the visit. The surgical ward is a 34 bed unit. It renders circumcision and amputation services. The sister in charge informed the committee that HIV prevalence is very high in the area and is the main cause of deaths.
7.5.2 FEMALE SURGICAL WARD
The female surgical ward is also a 34 bed unit. On the day of the visit, there was only one professional nurse who informed the committee that the ward admits diabetic, TB, and HIV patients. The critical HIV cases are isolated.
7.5.3 POSTNATAL WARD
The postnatal ward was severely understaffed.
7.5.4 RENAL UNIT
The renal unit is well equipped. One of the challenges the staff mentioned is that they are also servicing people from Lesotho.
7.5.5 INTENSIVE CARE UNIT (ICU)
The ICU has six beds and is short staffed. There is no qualified doctor running it. There is no equipment, especially the ventilators and monitors.
Due to infrastructural problems, part of the casualty unit is located in the X-ray ward. There are five radiographers in the X-ray unit. They are using the X-ray for diagnostic purposes. They are using advanced equipment which is safe for use even by pregnant women. The only challenge is the dysfunctional tele-radiology because Pelonomi has upgraded and synchronising of tele-radiology is taking long.
7.5.7 LABOUR WARD
The labour ward admits level two patients. They deal with referred patients but faced with the challenge of self referrals. Patients that were unable to handle were referred to Pelonomi hospital. The labour ward is short staffed and there is no gynaecologist.
8. BONGANI HOSPITAL
DELEGATION FROM THE HOSPITAL
1. Ms Alida Zwieqela: District Director
2. Ms Dorothy Johnson: Nursing Manager
3. Ms Cornelius E Moshane: Client Service Manager
4. Ms WI Hlanane: Chief Medical Officer
5. Mr TJ Talane: Acting CEO
6. Ms Aha Lowe: Client Service Manager
Bongani hospital is a modern complex that was officially opened in 1994. The planning and building of the hospital was a timeous and costly process which took approximately 14 years to complete. The total number of beds is 460 with a staff compliment of 848. The hospital serves the catchment areas of Katleho, Winburg District Hospital complex, Thusanong, Nala, Mohau District Hospital complex and 25 clinics in Lejweleputswa District.
8.1 CHALLENGES FACED BY THE HOSPITAL
The challenges were imposed by the limited resources and are exacerbated by the following issues:
- The fact that 86.3% of the Lejwejeputswa population is dependant on Bongani Hospital for care posed a major challenge for the hospital. There is no district hospital and community health centre in Welkom. There is no health service operating for 24 hours except for 1 clinic.
- There is limited availability of health professionals which resulted in high vacancy rates particularly in areas of great need. The hospital is unable to retain staff due to its rural nature.
- The high level of poverty in the community is a major challenge for the hospital. The high burden of disease especially the current HIV/AIDS and Tuberculosis epidemic had a major impact on the health status of the community.
8.2 CHALLENGES FACED BY STAFF
v Chronic staff shortages,
v Retention of Medical Officers,
v Outdated equipment,
v Shortage of consumables,
v Pressure of implementing unfunded mandates like the HCT, and
v Perception that management do not care because they were not doing anything to change the situation.
v Community Service doctors were used for service instead of training
8.3 WALK ABOUT AT THE HOSPITAL
There are four rooms that are supposed to be used for X-ray and only two are working. The other two rooms are not working since 2009 and nothing was done about it. There is equipment shortages and were using a very old scanner that was purchased in 1994.
8.3.2 VASCULAR ROOM
The vascular room was not utilised as there is no radiologists. The processors are old and only one is working. When it breaks they have to close.
8.3.3 DENTAL X-RAY
The room is full of old machines that are not working and could not be repaired.
8.3.4 CASUALTY WARD
Due to staff shortages, the casualty had to close. The selection of applicants was submitted three months ago and they were still awaiting appointments.
8.3.5 NEONATAL ICU
The capacity of the neonatal ICU is 16 but sometimes they have to admit 30 neonates. Each nurse takes care of 4 to 5 patients at a time. There were staff shortages and operations were done on a first come basis.
9. PELONOMI HOSPITAL
DELEGATION FROM THE HOSPITAL
1. Dr KK Moeng: Acting CEO
2. Ms SRO Khokho: Executive Manager for Strategic Health Programme and Medical Support Services
3. Mr E Pelelo: Acting Executive Manager Provincial Health Services
4. Ms NC Mzozoyana: Chief Financial Officer
5. Ms B Ramolula: Acting Head
6. Mr GJ Kgasane: Head Pharmacy
7. Ms LC Peens: Acting Head Allied Health Services
8. Mr J Mbalula: Head of Communications in the Free State
9. Mr MW Fikizolo: Executive Manager Resource Management Support
10.Mr LA Khiba: Head Technical Support
11. Ms MC Molefe: Head of Nursing
Pelonomi Hospital is a 720 bed institution but currently utilises 469 beds. It was officially classified as a regional or secondary level hospital but also renders tertiary services for the province, other provinces andLesotho. The institution is situated in Bloemfontein and accepts referrals mainly from Motheo and Xhariep Districts, the rest of the Free State Province for the designated tertiary services, Eastern Cape and Lesotho. The hospital was also used as a training institution for medical students. The hospital is in the revitalisation programme. The Radiology Department with its 64 slicer CAT Scan is completed. The ICU was handed over for revitalisation.
9.2 HIGHLIGHTS FOR THE HOSPITAL
The hospital was one of the hospitals that were designated for the FIFA 2010 World Cup and was in Public Private Partnership (PPP) with Netcare during that time. The province experienced a shortage of pharmaceuticals but that has improved because they have 90% of medicals including medical consumables.
9.3 SERVICES CHALLENGES
v The department was once managed by Treasury which was one of the reasons there was a delay in the filling of posts which resulted in a backlog.
v There were restrictions due to budget constraints
v There were long delays in filling of posts like cleaners and others. The management also mentioned that they had a meeting two weeks ago to prioritise posts and some personnel categories were outsourced but were going to absorb them.
v The hospital lifts were very old and they could no longer get parts. The management mentioned that they have issued a tender to replace all the lifts in April and the tender was approved. The Hospital was going to start with the replacement in August 2010.
9.4 PROGRESS REPORT ON HCT PROGRAM
The HCT program is running for approximately one month, and is gaining momentum. Seventy rapid tests were done during the last 30 days.
v MIND SHIFTING: For years the sentiment from the health department was not to encourage active screening for HIV. That policy has become entrenched in the clinical settings. Turning the sentiment around takes time and effort. Some patients and doctors still have a subconscious notion of “no test, no trouble”.
v The fear of being confronted by a terminal illness was a serious issue and living in denial was making some sense to some people.
v Some patients had the notion that a positive HIV result will make them second class patients.
v The fear of social rejection and financial hardship was also in existence.
9.6 PERSONNEL FACTORS
- Mind shifting,
- Taking the responsibility of determining a life/death test,
- Personnel shortages, and
- Doing laboratory work.
- Mind shifting for patients and personnel,
- Site visits were commenced on the 4th August 2010, and
- Circumcision blitz planned.
9.8 WALK ABOUT AT THE HOSPITAL
9.8.1 BURNS UNIT
The burns unit is a 23 bed unit which offers tertiary services. The facility started seven years ago. It caters for children and adults. There are two doctors and one registrar in-charge of the unit. The unit was empty and weather related conditions were stated as reasons for the empty unit.
When officials were asked about water which was once a challenge in the hospital especially at the burns unit, he informed the committee that the municipality was struggling to push water up to the seventh floor but that has improved and they were no longer struggling with water shortages.
The committee was also shown a unit that was going to be used for burns patients. Due to budget constraints they could not open the unit but they highlighted that it was not expensive to open the unit and were considering ways of working on opening it again.
9.8.2 HIGH CARE:
The high care unit was opened in 2006 and was regarded as the best trauma unit in the Southern part. It is a 24 hour service and operates for seven days a week. It admits patients from Eastern Cape, Western Cape and Lesotho. In a case of a disaster, a triage area was opened to sort patients and prioritise those with serious injuries. They have 18 bed cubicles and each had its own monitor and ventilator.
9.8.3 LODOX ROOM
The lodox room had the most advanced equipment used to scan the whole body in 13 seconds and identifies injuries.
9.8.4 RENAL UNIT
The renal unit was a 13 bed unit and functions well. The staff highlighted staff shortages as their only challenge.
The Committee was taken to the PPP. The partnership was working very well and the only challenge that was highlighted was that doctors were spending more time at the private part whereas they were employed by the public sector.
10. UNIVERSITAS HOSPITAL
DELEGATION FROM THE HOSPITAL
1. Mr Jones Nkhatho: Assistant Manager (Nursing)
2. Mr Lebusa Semela: Manager – Administration
3. Ms Nomasundu Nyangintsimbi: Assistant Manager (Nursing)
4. Mr R Dreyer: Manager – Finance
5. Ms NE Mathobisa: HIV and AIDS and TB Coordinator
6. Ms Mohutsiwa Tihogo: Senior Manager
7. Ms Eona Terblanche: Assistant Manager – Human Resources
8. Dr Van Zyl: Head – Clinical Services
9. Ms Nolwandle Mashiane: Board Member
The CEO, Reverend Musapelo welcomed the committee and informed the committee that in a bid to support the Minister’s call of having all South Africans being screened for HIV and knowing their status, Universitas Academic Hospital has established a HCT Nerve Centre where the beneficiaries of the service will have themselves tested. The HCT Nerve Centre was designated clinic for HIV testing with permanent staff allocated to it.
Services that were rendered included screening for diabetes mellitus, 2 rapid tests for HIV, Anaemia, Hypertension, TB and Sexual Transmitted Infections.
The responsibility of the Nerve Centre was to supply testing kits and condoms to institutions like Pelonomi, Rosebank, Medi-Clinic, 3 military Hospitals and 4 tertiary training institutions, training of staff on counselling and performance of HIV testing and interpretation of results, consolidation of HCT statistics from all partners and support to institutions during their wellness days.
10.1 MANAGEMENT OF HIV PREVALANCE, MDR AND XDR TB
v All the wards and outpatient departments are supplied with testing kits to offer rapid tests to admitted patients.
v Unit managers have been trained on how to perform and interpret the results.
v On the day of the visit, there were only three professional nurses on duty and they highlighted that they were short staffed and sometimes nurses have to attend meetings and also escort patients toManapo Hospital when a need arises.
v All patients and visitors that test positive for any of the abovementioned diseases, further tests are done to confirm the diagnosis and are then treated and referred accordingly.
v Although Universitas Academic Hospital is a tertiary institution which did not render TB services, it is only available if a patient is identified and in need of the service. Each ward has a TB representative who is trained on basic TB management.
v Should results be available after a patient has been discharged, the patient is contacted and treatment initiated via the local clinic near his/her local place or residence. Those who still have to come for follow up are called in and treatment initiated.
v Upon discharge, patients are properly referred to their local clinics.
v There is a system in place for reporting TB cases diagnosed in hospital to the district office and reporting is done on monthly basis.
v A ward was identified in the hospital where TB and MDR patients are admitted. The infrastructure had been altered in such a manner that negative suction is created to minimise the risk of cross infection. This was created through the installation of extractor fans.
10.2 INFECTION CONTROL
Infection control is the responsibility of the Prevention and Control Unit to ensure that handwashing facilities are always available in the wards. There are hand wash posters next to each basin as reminders to officials that the practice has to be adhered to at all times. The unit also ensures personal protective clothing is always available and appropriately used to protect staff as well as prevention of cross infection.
There is close collaboration between the Infection and Control Unit and the cleaning company contracted by the institution and a checklist was developed which served as a road map to the cleaning company regarding evaluation of their services.
In cases where a patient is harbouring a communicable disease, she/he is nursed in isolation.
The water utilised by beneficiaries of the services is safe for human consumption and free of pathogenic organisms. Sampling is done on a yearly basis to rule out the possibility of water harbouring Legionella. For 2010 the sampling was done on the 13th of April and results were made available on the 28th April 2010. In all the departments where samples were taken, tested negative for Legionella, except for water samples were taken from the Paediatric Cardiology and Coronary intensive Care Units. The technical services section was alerted and the water in all the hospital’s reservoirs is appropriately treated.
To render the hospital free of pests and other insect vectors, Africa Pest Control had been contracted by the institution to render the service and all areas within the institution are treated at six weekly intervals.
10.3 WALK ABOUT AT THE HOSPITAL
Pharmacy provides a 24 hour service. There was 85% of stock availability and the challenge that was highlighted was delay in getting orders back from the medical depo and sometimes they had to get stock from other institutions. The other challenge that is long waiting times which sometimes take 3 hours to attend to patients.
The unit is an 8 bed unit but only used 6 and the 7th bed is only used if there is an emergency. There is also an arrangement with Netcare to borrow a bed from them when there was a shortage. The borrowed bed was subsequently taken back when beds were available. They also have an arrangement with the private sector to buy services. The ICU is a multi disciplinary unit which admits medically related conditions. However, it does not admit children. The staff mentioned that they were coping with the equipment although it was old and it was not taking them more than a week to get their machines fixed. They borrowed from Pelonomi Hospital when there were stock outs.
10.3.3 PRE-TERM WARD
The pre-term ward is a 12 bed unit. The infection in the ward is lower than the national norms and sepsis which was the cause of death to some babies was from outside. The challenge the pre-term ward faced is the shortage of equipment like monitors and transport incubators.
10.3.4 MARTENITY WARD
The maternity ward is a 20 bed unit with 20 patients. There were only 2 sisters on duty. The maternity ward was short staffed and they were also struggling with equipment.
11. PROVINCIAL MEDICAL DEPO
The responsibility of the medical depot was to order and keep stock for institutions. It is also responsible for preparing contracts for institutions. Its budget is not centralised at the depo.
The challenges that were mentioned at the medical depot were that institutions were not making orders frequently which made it difficult for the depot to place orders on time.
The other challenge the depot was faced with was that institutions were not doing their stock control which resulted in medication getting old at the depot.
There were late payments of the depot by institutions.
12. FINDINGS BY THE COMMITTEE
1. The primary healthcare was not functioning well in the province.
2. There was no infection control policy on the institutions
3. There was no delegation of powers to hospital CEO’s and hospitals could not even buy medical consumables like gloves.
4. There was no Maintenance budget at all hospitals, as well as provincial level.
5. There was no monitoring between the hospitals and the provincial department. (The PDMS of Hospital managers).
6. There was no involvement of hospitals in budgeting processes.
7. There was no support given by the province in supervising the health institutions and in supporting them with the budget.
8. Elizabeth Ross, Bongani, Manapo and Pelonomi were not communicating with each other for benchmarking purposes.
9. There was malfunctioning management at Bongani Hospital
10. There is no communication between the medical depot and the hospitals.
11. There were severe Human Resources shortages in all the institutions.
12. Budgeted posts were not filled when they become vacant.
13. There were severe shortages of equipment in the province especially at Pelonomi.
14. The Maternity ward at Pelonomi Hospital was under tremendous pressure due to staff shortages and equipment
15. There is no provincial strategy for recruitment and retention of medical staff.
16. The OSD was not working well and it was causing animosity or friction between staff.
17. There were unfunded mandates especially at Bongani Hospital
18. There were long waiting periods for patients (especially at Elizabeth Ross, Bongani and Pelonomi).
19. There were ambulance shortages in the province.
20. Community doctors were used for service instead of training.
21. Pelonomi Hospital seemed not to be working with Universitas Hospital
13. DELEGATION FROM THE PROVINCIAL DEPARTMENT
1. Dr Sipho Kabane: Head of Department
2. Ms Khumo Mzozoyana: Chief Financial Officer
2. Ms MCL Mabitle: General Manager
3. Ms Yolisa Tsibolane: Senior Manager
13.1 RESPONSES FROM THE DEPARTMENT
A number of findings were highlighted during the oversight trip by the Portfolio Committee. These were responded to by the Department. Following below are detailed responses to some of the issues highlighted:
Overcrowded Casualties wards are a reflection of poor Primary Health Care (PHC). This is one of the weakest areas because of over-referrals. This is a complex problem given the high burden of disease, the rural nature of the province and high unemployment rate. Facilities appear small for the population, however the province is “losing people” through migration and there should be a greater emphasis on building Community Health Centres (CHCs). The Hospital Revitalisation process looks at organisational development, quality, systems, and many more. It is currently being carried out at Pelonomi and Boitumelo. Others are still in the planning stage. The pace of revitalisation is slow, but comprehensive, including both the equipment and staff issues in a phased approach.
Personnel shortage is a serious problem given the rural nature of the province, making recruitment and retention of health care professionals difficult. For example, at Nala Hospital, which is an ARV site, there are no doctors. The staff establishment was declining due to declining funds allocated to staff salaries. Occupation Specific Dispensation (OSD) has not assisted the situation. It often complicates matters by, for example, requiring funds to be shifted away from vacant posts. The rural nature of the province, especially in places like Qwaqwa where accommodation was scarce, presented a challenge to attracting health care professionals. Advertising was done via the centralised provincial government advertisements and was no longer a departmental function. This posed a challenge in filling posts quickly. A nursing school in Thaba Nchu was opened, addressing the accommodation needs of nursing students. There was a need to prioritise and balance staff and goods and services. The department was currently reviewing the structure of the department which was currently divided into four clusters: finance, resources, clinical (district) and strategic programmes. There was a lack of proper co-ordination between the Corporate Office and the districts, which the department claimed to be correcting. In particular, the department was reviewing the large administration staff (versus the need for clinical skills). The Performance management system (PDMS) was faced with challenges. Health care workers wrongly viewed this as a cash bonus or pay progression, whereas it was supposed to be a performance- based bonus. In 2007/08 and 2008/09 the department had no cash for the bonuses. A court order required the department to pay but due to financial constraints this was not done- i.e. the department had not budgeted for it.
At 4 of the 6 institutions visited, there were acting CEOs. According to the department, acting CEOs of institutions tend to do the minimum required of them because they know they were only acting and will be replaced. Greater supervision was required from general managers especially when acting CEOs were place. The Head of Department described Bongani Hospital as having “collapsed”, with serious management issues. He also identified Pelonomi Hospital as having management issues.
Delegations: The Head of Department stated that, in the previous term, CEOs and district managers had certain powers (such as to hire staff and procure medication) but these were removed in the new political term. The challenge was to bring back those powers. The Executive Council had approved a Policy Framework. Departments have customised and submitted to the Premier’s office and were awaiting final approval. However the main challenge was accountability and proper governance. The new delegations spelt out requirements with regard to bid committee, finance, supply chain management and personnel.
The health budget has increased from 24% of the provincial budget in 2009 to 29% in 2010. However, the increased mandates of the HIV Counselling and Treatment (HCT) and Immunisation Campaigns had an impact.
Medical Depot: The institutions visited raised a number of issues about the Medical Depot, including not having stock of TB medication and “basic medication”. At one institution, the pharmacist in charge had to improvise medication using existing stock because TB syrup was not available. However, according to the department the Medical Depot was operating as it should. There was a lead time of 6-8 weeks and institutions were not placing their orders timeously. Institutions were not supposed to wait till the last of their medication was depleted before ordering. Also there were problems with National tenders and there were times when the supplier was out of stock. Furthermore, the Depot required timeous payment from institutions however this was not always happening. The system needed review in terms of cash flow. R40 million was advanced to the Depot in June 2010 and, according to the department, it was not experiencing major financial constraints. A new management structure was proposed for the Depot and the department was also considering outsourcing the Depot.
Emergency Medical Services (EMS) response time remained a challenge. The province was faced with a shortage of personnel and ambulances. According to the HOD, the national norm was 1: 100,000. Since the province had a population of 2.9 million, it should have 290 ambulances, but only had 120-130 functioning ambulances according to the department. In October/November 2009 40 new ambulances were procured and in April 2010 an additional 60. However, because of the age of the existing fleet many were replaced and not added to. The department was leasing ambulances through the government garage. Each ambulance needed 8 to 10 person crew. The department planned to place certain ambulances in the districts but they needed additional ambulances and personnel. The province had opened its own EMS College to deal with the shortage of EMS staff in the province. The emergency helicopter contract was currently being reviewed and might not be renewed, given the high costs and limited service offered.
3-5% of the budget was set aside for maintenance. A provincial level fund has been set up to deal with larger maintenance problems.
Community Doctors from Bongani Hospital raised the following issues:
Interns and Community Service doctors were used for service provision as opposed to training. Community service doctors were put on call without back-up supervision or assistance. They reported that the Head of Department was not available for supervision and there were internal management problems between doctors in charge. There was a lack of learning opportunities as they were not rotated to the various wards. Casualty was used as a polyclinic. There were gaps in the roster and there was no 24-hour doctor available. Patients were not sorted to prioritised according to their health status. They reported a shortage of equipment and lack of maintenance as vital equipment was always out of order.
The HOD announced that Bongani Hospital had “collapsed”. He indicated that managers hide what was happening at institutions. The auditors had also noted problems at the institution. He announced that the department was going to re-introduce staff indabas and that the HOD, with relevant senior managers will spend one week at Bongani Hospital. He further indicated that the hospital had sufficient doctors but were not properly deployed and needed leadership. The Department would do the same at Pelonomi Hospital. The Committee was concerned that the Department was only going to respond now that the Portfolio Committee had visited whereas they were aware of the problems even before the visit.
14. RECOMMENDATIONS BY THE COMMITTEE
a) The province should revive the Primary Health Care.
b) There should be an infection control policy and strategies and institutions should adhere to them.
c) The Delegation of powers to hospital CEOs be attended to as a matter of urgency.
d) Human Resources challenges should be addressed urgently.
e) Acting positions to be filled as a matter of urgency especially at managerial level.
f) The Department should liaise with Telkom to resolve the communication challenges.
g) The Provincial Department of Health should work with the Department of Home Affairs to address the utilisation of South African Health facilities by foreign patients.
h) There should be proper communication between the National Department of Health and the Province to the staff of what OSD is.
i) The Province should look at and attend to the management issues at Bongani Hospital.
j) The Province should relocate the ambulances that were used during the 2010 FIFA World Cup.
k) Community Service Doctors should always be under supervision.
l) Pelonomi and Universitas should be brought together, rationalise services and specialise on different services.
v The Committee would like to extend its gratitude to Sister Mohale who is responsible for the Step Down and Step Up ward at Elizabeth Ross and who is passionate and committed to what she is doing.
v The Committee would also like to appreciate the good work that is done by Mofumahadi Manapo Mopeli Hospital with the little resources they have.
v The Committee would also like to appreciate the good work which is done by a doctor that was responsible for the Emergency ward at Pelonomi Hospital.
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