ATC140404: Report of the Portfolio Committee on Health on oversight visit to Mpumalanga Province from the 16 to 17 September 2013, dated 12 March 2014
Report of the Portfolio Committee on Health
on oversight visit to Mpumalanga Province from the 16 to 17 September 2013,
dated 12 March 2014
Portfolio Committee on Health (the Committee) having undertaken an oversight
visit to Mpumalanga Province from 16 - 17 September 2013 reports as follows:
of the functions of the Portfolio Committee on Health is to conduct
The Committee therefore
conducted its oversight visit in Mpumalanga Province from the 16 to 17
September 2013. The purpose of the visit was to assess infection control
strategies and the quality of health services, the referral system and the
functioning of the primary health care system, roll out of ARVs and drug stock
outs, achievements and challenges with the roll out of the National Health
Insurance Pilot Project.
also wanted to gain insight into the functioning and recruitment of retired
nurses, how they are compensated and their scope of work.
The Committee also wanted to assess
revitalisation projects and their functionality as well get a report on the
deaths of initiates.
delegation comprised of the following Members of Parliament:
MB Goqwana (ANC and the Chairperson of the Committee); Ms TE Kenye
(ANC); Ms BT Ngcobo
Ms SP Kopane (DA);
and Ms H
following officials accompanied the delegation:
Ms Vuyokazi Majalamba (Committee Secretary);
Ms Nombali Magubane (Committee Assistant);
Mr Moses Mncwabe
Ms Lindokuhle Ngomane (Content Advisor) .
3. The Committee visited the
following public health facilities:
Hospital, Verena Community Health Centre and Ermelo Hospital.
4. OVERSIGHT AT KWAMHLANGA
On the 16 September 2013, the Committee
conducted its oversight at KwaMhlanga Hospital. The Committee met the following
delegation at the hospital:
Ms Nokwanda Phokoje (Acting Chief
Executive Officer (CEO); Dr G Thwala Nkangala (District Coordinator); Ms TB
Nkosi (Assistant Director); Mr VW Mndebele (Pharmacy Supervisor); Ms LB Lukhele
(Operational Manager); Mrs NN Masilela
(Assistant Director); Ms MM Mabena (Quality Assurance); Mr JK
(Delegated IPC); Ms ET Masemola
(Secretary to the CEO); Ms PT Tause
(Emergency Services Coordinator); and Mr JM Thamasa (SSA).
Ms Phokoje briefed the Committee and
gave a background of the district municipality.
She informed the Committee that Thembisile Hani Local Municipality is
located in the Nkangala District Municipality of Mpumalanga Province and is a
semi-urban Local Municipality. The geographical area of the municipality is
approximately 2493.49 square kilometres.
The municipality forms part of a larger economic sub-region of Tshwane
and Johannesburg and that the municipal offices and chambers are located in
She also noted that the majority of the
people in Thembisile Hani Local Municipality are still very young according to
the population data and are aged between 0 and 24 years old.
The percentage of pensioners in Thembisile
Hani Local Municipality is 4.8% as compared to 4.4% of the province and 4% in
Ms Phokoje also noted
that the level of education in Thembisile Hani Local Municipality was low which
indirectly affected the health and life expectancy.
The Acting CEO informed the Committee
that Kwa-Mhlanga hospital was classified as a District level one hospital and
provides comprehensive care on a 24 hour basis.
It provides inpatient care for treatment of common diseases, injuries
and normal deliveries.
It is a
non-specialty facility to which patients from the surrounding clinics are
The hospital is in a rural
area and its nearest provincial referral hospital is Witbank Hospital which is
112 km away from Kwa-Mhlanga Hospital.
Services that are provided at the
hospital are as follows: general wards, maternity ward, paediatric ward, 72
hour mental health services, victim empowerment room, theatre, 24 hour casualty
department, general outpatients for patients referred from the clinics and self
referrals and wellness clinic.
offered under allied health services are speech and audiology, social worker,
radiographic, physiotherapy, occupational and clinical psychology
The clinical health services
that are offered at the hospital are dental, medical and pharmaceutical
Other services that provided by the
hospital under support services includes; laundry, CSSD, food, housekeeping,
maintenance, security services, labour relations, human resource, finance,
procurement and provisioning, asset management, transport and hospital
Health services in the Primary Health
Care are provided through the following facilities: 20 primary health facilities
which 14 are eight hour clinics and six are twenty four hours community health
There are also four mobile
clinics that are servicing 17 points.
The inpatient bed utilisation rate was
at 58% in April, 66% in May, and 68% in June. The caesarean section rate was
above 10% in April, at 20% in May and above 15% in June.
On quality assurance the Acting CEO
highlighted that the hospital has a dedicated professional nurse doing quality
management and another professional nurse dedicated for infection prevention
The hospital has also
developed quality improvement plans with special focus on fast tracking the
ministerial six priorities.
satisfactory and patient time surveys have been conducted. The institution was
also reinforcing hand washing to break the chain of infection and cross
The hospital was also
planning to improve management of waste on medical, domestic and
The institution was also
planning on intensifying surveillance of communicable diseases and notification
and monitoring of compliance to policies and QIPs.
On quality assurance the hospital was
improving the management of dirty linen with more focus on proper handling and
Ms Phokoje noted that drug stock
availability stands at 86% due to revised drug list and that ARV roll out was
an ongoing process and the total number of patients already on ART stood at
28836 apart from the patients that remained on ART newly initiated for the
current financial year was 1056 for Kwa-Mhlanga Hospital.
On referral system the Acting CEO noted
that the health system within the Mpumalanga Province began at the Primary
Health Care level where the referral system begins.
Patients within the community start at a
local clinic as the first point of entry and if the need of a patient surpasses
what the clinic can offer, they are then referred to a district hospital.
The next level of referral from a district is
a tertiary hospital.
Witbank does not
have a full package for a tertiary hospital and it is for that reason that the
province is having a Memorandum of Agreement with the Gauteng Provincial
Department of Health for services that cannot be provided such as oncology,
urology and neuro-surgical services.
The vacancy rate for management and
support staff is at 67% with 42% for dentists, 34% for professional nurses, 75%
for nursing assistants, 100% for pupil nurses, 68% for pharmacists, 27% for
radiographers, 78% for physiotherapists, 63% for occupational therapist, 20%
for pharmacy assistants,
25% for dental
assistants, 50% for occupational therapist assistants, 50% for speech
therapists, 54% for finance, 100% for audiologists, 100% for oral hygienists,
100% for dental therapists, 83% for darkroom attendance, 67% for medical social
worker , 0% for groundsman, 63% for corporate services and 41% for cleaners.
The total budget for Kwa-Mhlanga
Hospital for the current financial was R130, 789,000 million.
The bulk of the budget (R110 million) is
allocated to compensation of employees, with R19million has been allocated for
goods and services. Six thousand has been allocated for provincial and local
government. Forty seven thousand has been allocated to transfers and households
while R917, 000 has been allocated to capital.
The hospital has overspent by 194% on provincial and local governments
and 498% for transfers and households.
The overall maintenance budget for
2013/13 is at R300, 000.
infrastructure maintenance budget was R150, 000 and the expenditure including
commitments was at R2, 690. The maintenance of medical equipment budget
allocation for 2013/14 was R150, 000 and the expenditure including commitments
was at R30, 742.
infrastructure, the Acting CEO highlighted that progress made on revitalisation
of the ICU was at 99%, the old theatre not yet started, new OPD at 98%, old OPD
and admission at 76%, public toilets were completed while the new gas plant
room was at 75%.The borehole was finished but cannot pump water.
4.3 The following were
challenges facing KwaMhlanga Hospital:
The mortuary, laundry,
kitchen, pharmacy and maternity ward are too small and the medical waste
storage area was also too small.
The fence for the hospital
There is insufficient
accommodation for all health professionals which makes it difficult to attract
and retain staff.
5. OVERSIGHT AT VERENA
COMMUNITY HEALTH CENTRE
Committee met with the following delegation at the health centre:
Mrs Cheryl Nelson (Primary Health Care
Director); Ms E Monapa (Operational Manager); Ms TB Nkosi (Assistant Director
for Primary Health Care); and Mrs LN Fakude (Assistant Director HAS).
Mrs Nelson briefed the Committee in
Verena CHC which was established as a mobile point in 1997 with one
professional nurse and an assistant nurse.
The services that were rendered in the container were donated by Astra
The current structure was
erected and started to operate as an eight hour service in 2000 and in 2002
began to operate as a 24 hour facility.
The facility is situated 50 kilometres away from Bronkhortspruit and 45
kilometres from Kwa-Mhlanga Hospital. The CHC serves all the sections of Verena
community including Langkloof area, Wolwenkop, Rietfontein and the catchment
population is estimated at 19647.
There are eight pre-schools, three
primary schools, three secondary schools and three high schools in Verena.
The other community structures are one drop
in centre, two disability centres, nine taverns, eight shops, six spaza shops
and nine day care centres.
The Primary Health Care Director also
noted that most the Verena community has a high employment rate and those who
are working are travelling to Witbank and Gauteng and others are self
There is no public transport
to Langkloof except hitch hiking and there is also no fixed health facility and
that community uses a mobile facility.
The disease profile for the area is HIV
and AIDS with 521 adults remaining on ART and 67 children under 15 years also
remaining on ART, mental health, sexual transmitted infections (STI), diarrhoea
in children under five years, pneumonia and hypertension and diabetes
Services that are rendered at the CHC
are HIV management including initiation on Antiretroviral therapy, minor
ailments, chronic and geriatrics care management, TB management, voluntary HIV
counselling and testing, mental health, sexual reproductive health (family
planning), antenatal and postnatal care, management of labour and deliveries,
rehabilitation, dental and child health care services, communicable disease
control services, expanded program in immunization, pre and post counselling
for Choice of Termination of Pregnancy (CTOP), post prophylaxis exposure,
mobile service with five points, eye care services and the CHC is still going
to launch the voluntary male medical circumcision (VMMC).
On referral system Mrs Nelosn noted that
Dr Baloyi visits the facility every Friday.
The facility refers to Kwa Mhlanga hospital for emergency cases and
There is no
facility that refers to Verena due to its geographical location.
Patients who need social services are
referred to SASSA on site.
The CHC also
has a referral register which guide which assist when they referred.
5.1 Governing Structures
primary health care director highlighted that the CHC works together with the
clinic committee that has been appointed and trained and that the committee was
nominated to serve for a period of three years.
The structure of the clinic committee consists of ten members as
5.2 Infection Prevention and
On infection prevention and control, it
was noted that a quality assurance committee has been appointed in January 2013
with terms of reference that outlines their duties and their
The infection prevention
and control policy and the quality improvement plan are also available.
There is a dashboard for tracking and
monitoring the six ministerial priorities and the CHC gets feedback from the
community on how they progress on those priorities.
5.3 Drug Availability
The CHC has a drug stock register that
is available where drugs that are out of stock are recorded.
There is a dash board on drug availability
has been implemented. There was a 0% in the first quarter for tracer item stock
5.4 Human Resources
On human resources, the CHC currently
has 18 professional nurses (requires five additional nurses),
six enrolled nursed (need three more), e two
enrolled nursing assistants (need six more), no pharmacy assistant, no health
promoter, four cleaners (need three more) and have no grounds man
5.5 Indicator Report
The community of Verena visit the health
centre 3.5 days a year. Pregnant women come late to the clinic and some after
The antenatal first visit
before 20 weeks was at 28.7% against the target of 40%.
The immunisation coverage for under one year
was at 66.9% against the 90% target.
community of Verena was not using family planning programme which led to the
health centre achieving only 22.4% coverage against the target of 70%. The male
condom distribution was at 14.2% against the target of 15%.
Nelson noted the following as achievements for the CHC:
The clinic committee has
been appointed and trained;
There is a primary health
care outreach team has been servicing the Verena area;
The health centre has a
computer and printer;
The park home has been
The governance structure has
There is a shortage of
administration clerks to retrieve patients files but a submission has been
made to appoint an administration clerk.
There is shortage of office
furniture and equipment for new park homes as an extension to the
A requisition has been send
and the CHC is awaiting procurement and delivery.
Nelson made the following recommendations on behalf of the CHC:
Facility data reviews should
The interior of the facility
should be repainted.
The ceiling in the maternity
and VCT section need to be repaired.
The male staff toilets and
carport should be constructed.
Vacant funded posts should
6. OVERSIGHT AT ERMELO
Committee met with the following delegation at Ermelo Hospital:
Fridah BG Nyathi
Officer (CEO); Ms Nanana Hlatshwayo
(Chief executive Officer for the Evander Hospital); Mr Erence Mmola
(Deputy Director: Expenditure and Monitoring), Mr Mandla Kamabuza (Assistant
Director for Primary Health Care); Mr Moses Siphuma (Assistant Director for
Primary Health Care at Chief Albert Luthuli); Ms Faith Dimakatso Mafammer
(Deputy Director for Primary Health Care); Ms NE Mnisi (Nursing Service
Manager); Mr SI Magaba
for Corporate Services); Mr TM Sonqwenqwe (Project Manager for Hospital
Revitalisation); Dr S Mohangi (Project Manager for National Health Insurance
(NHI); Mr GS Ntshangase (National Core Standards); Mrs NC Mabaso (HAS
coordinator for Albert Luthuli Sub-district); Mrs MA Hattingh (Infection
Prevention and Control Coordinator); Mrs LE Oosthuizen (Quality Assurance
Coordinator); Dr Thokozani Mhlongo (Deputy Director-General for District Health
Services); and Mr VE Khoza (Chief Director GSD).
Nyathi made the presentation to the Committee and gave an introduction to the
She informed the
Committee that Ermelo Hospital is a regional hospital (level 2) with 264
approved beds and 216 usable beds.
hospital is within the Msukaligwa Sub-district in the Gert Sibande District.
The hospital was officially opened in
It had two wings for the African
and White community which were merged in 1994 and made accessible to all racial
In 2005 the hospital was placed
onto the hospital revitalisation programme.
Ermelo Hospital is a referral hospital to all eight district hospitals
within the Gert Sibande District Municipality as well as being a referral
centre for 11 primary health care facilities within the Msukaligwa
population trends indicate that there is a tremendous growth of 19.7% between
2001 and 2011 and it is currently at an estimated growth rate of 1.8% per
The largest age group are adults
between the ages 20-49 years which comprises of 67 873 of the population,
followed by children between the ages of 10-19 years who comprises 29 048 of
The under five year old
comprise of 16 574 of the population.
females contribute 50.4% and males 49.6% of the total population.
Nearly 27% of the population of Msukaligwa
are aged between 15-64 years and are unemployed.
The leading industries in terms of employment
in Msukaligwa are agriculture, community services, and trade.
Eighty four percent of the population of
Msukaligwa is uninsured and 26.8% is unemployed of these 12.3% of the
population above 20 years of age has no schooling.
6.1 Disease Profile
On disease profile, the
sub-district is like the rest of the county as it faces a quadruple burden of
diseases like HIV and AIDS, tuberculosis, high maternal and child mortality,
non-communicable diseases, violence and injuries.
Compounding on these unfavourable conditions
are socio-economic determinants of health such as poverty and inadequate access
to essential services such as electricity, proper sanitation and access to potable
The HIV epidemic in
Msukaligwa sub-district has a profound impact on society, the economy as well
as the health sector and contributes to a decline in life expectancy, increased
infant and child mortality and maternal deaths.
According to the latest Antenatal Care survey for 2011, Msukaligwa
sub-district is the third highest in HIV prevalence in the whole of Gert
Sibande District, thus the 5
highest in the Mpumalanga
The Anti Retroviral Treatment
(ART), Prevention of Mother to Child Transmission (PMTCT) and medical male
circumcision programmes is provided within the health facilities in the
Tuberculosis is both a
medical condition and a social problem linked to poverty-related
The combination of TB, HIV and
drug resistant TB has led to a situation where TB is the number one cause of
death among infected patients in Msukaligwa District.
TB treatment is provided in Ermelo Hospital
and all other health care facilities.
Ward based teams in wards 15, 17 and 19 provide support to TB and also
support patients on Directly Observed Therapy throughout the municipality.
The leading causes of death
for under one year old age group are pneumonia, diarrhoea and malnutrition. The
leading causes of death for under five year old age group are pneumonia and
The most common
non-communicable diseases within the sub-district is hypertension and diabetes
6.2 Emergency Medical
state of most of the municipal roads especially the gravel roads are bad with
poor storm water drainage.
negatively on the EMS response times.
total budget for the hospital for 2013/14 is R193 504 320 with
R155 212 000 allocated to the compensation of employees, R36, 258, 000 for
goods and services, R136 000 goes to transfers and R1 898 000 for
machinery and equipment.
6. 4 Caesarean Section
CEO informed the Committee that the caesarean rate was 1% above the norm,
mostly due to women who had poor progress during labour and pregnancy induced
To address this, the
hospital will conduct morbidity and mortality reviews.
patient day equivalent (PDE) the CEO noted that it has decreased mostly because
there has been a noted decrease in the number of outpatients department (OPD)
headcount since May 2013.
The reason for
the decrease in OPD headcount is the increase in the hours of operation of
primary health care (PHC) facilities in Msukaligwa sub-district which now opens
seven days in a week for a 12 hour day.
The average length of stay is 3.3% above the norm, mostly due to
Fourteen of the
inpatients with orthopaedic problems could not be transferred due to lack of
beds in receiving Witbank and Rob Ferreira Hospitals. To address this challenge
the hospital will revive the orthopaedic outreach services.
6.5 Quality Assurance
quality assurance the CEO reported that the facility has improvement team with
a team leader from the National Department of Health. All 12 facilities are
implementing facility improvement.
six priority areas of the National Core Standards are implemented and monitored
Drug availability is at
Waiting time surveys are
conducted monthly and currently the waiting time is at four hours.
Infection prevention control
plan has been developed, implemented and monitored.
Staff have been trained on infection
prevention and prevention (IPC).
On staff attitude, a
complaint register is implemented with 100% complaints resolved within 25
Monthly mini surveys are also
On patient safety, morbidity
and mortality reviews are conducted, pharmaceutical therapeutics committees
conducted, clinical governance committees appointed and standard operational
procedures reviewed and developed.
On cleanliness, a
housekeeping manual has been developed, cleaning scheduled and checklist
6.6 Referral System
referral system the CEO informed the Committee that Ermelo Hospital refers to
Witbank hospital and Rob Ferreira hospital.
The hospital faces challenges with referral of orthopaedic cases due to
receiving hospitals not having beds.
Msukaligwa sub-district does not have a district hospital and therefore
all patients from the 11 PHC facilities are referred to this hospital.
The EMS station at Ermelo hospital, like all
other EMS stations is centrally controlled in Secunda which sometimes causes
delays in transporting of patients to upper levels of care.
6.7 Drug Availability
CEO informed the Committee that the drug availability was at 91.4% and that
drugs are ordered from the depot on a month to month contract.
6.8 Primary Health Care
are three community health care centres (CHC) and eight clinics.
One of the CHCs opens for 12 hours, seven
days in a week and three of the two clinics opens 12 hours and seven days a
There were four mobile vehicles
which are now scratched off.
6.9 Problem Areas
following were noted as problem areas by the CEO:
Shortage of health care
Shortage of specialists
and non-functional lifts
Lack of capacity in the
Supply Chain Management unit
Delayed in the opening of
ICU unit due to renovations
following were noted as achievements:
Output 1: Increasing life
Mortality and morbidity
meetings are conducted
Screening of chronic
diseases as a part of the health care provider initiated HIV counselling and
Rendering of Anti retroviral
therapy (ART) to patients and the hospital is initiating the fixed dose
combination (FDC) to pregnant women and new HIV positive clients
Output 2: Decrease maternal
and child mortality
Maternal and perinatal
deaths morbidity and mortality reviews are conducted monthly
The hospital has opened a
high risk antenatal care and womens health clinic
Output 3: Combating HIV and
AIDS and STIs and decreasing the burden of disease from TB
All 12 facilities in
Msukaligwa are providing HCT and ART
The nevirapine uptake rate
for babies is at 100%
Output 4: Strengthen Health System Effectiveness
The core management team has
The hospital has taken over
Sesifuba TB hospital in June 2013
The hospital is being a
benchmark for other districts in terms of pharmaceutical management
The Hospital has appointed
infection prevention and control practitioner that are supporting primary
The availability of TB and
ARV drugs is at 100%
Committee had a walkabout at the hospital and noticed that the paediatric ward
is combined with medical and surgical wards and lifts which have been non
functional for three years
following were findings that were noted by the Committee after visiting the
different health facilities:
Hospital had a very high drug stock out rate (14%).
Committee also noted that there were many acting positions at KwaMhlanga
hospital which took long periods to be filled.
was no dedicated maternity ward at Kwamhlanga Hospital.
shortage of cleaners was also a concern as this can compromise infection
issue of referred patients not having dedicated transport was of a concern to
the Committee as patients only relied on ambulances.
is no dedicated doctor at Verena Community Health Care.
of Primary Health Care was a challenge at Ermelo Hospital and this was a
serious concern to the Committee as PHC is the policy of government.
is no emergency ambulance stationed at Ermelo Hospital.
Committee also noticed that all visited institutions have a high rate of
high prevalence of HIV and AIDS in the province was also raised as a concern by
Committee was concerned that the province was not taking urgent actions in
addressing the deaths of initiates.
caesarean rate was found to be high in all visited institutions
of Health should ensure the following:
the shortage and lack of patients transport.
a speedy revitalisation of the ICU unit at Ermelo Hospital.
the improvement in the standard of antenatal care so as to decrease high
perinatal mortality rate.
progress in the implementation of the NHI in Gert Sibande district.
strategies to decrease infants and under five mortality.
partnerships in the Gert Sibande district with the mining sector to address the
high incidence of HIV and TB.
province needs to urgently address the issue of staff shortages, as severe
shortages were identified in all health facilities visited.
province should ensure that the issue on the deaths of initiates is addressed
and should report to the Committee on progress.
Report to be
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