ATC180803: Report of the Select Committee on Social Services on an Oversight Visit to Xhariep District Municipality and Mangaung Metropolitan Municipality in the Free State Province 30 July – 3 August 2018
Report of the Select Committee on Social Services on an Oversight Visit to Xhariep District Municipality and Mangaung Metropolitan Municipality in the Free State Province 30 July – 3 August 2018
TABLE OF CONTENTS
- Ms LC Dlamini – Chairperson: Select Committee on Social Services
2. Ms PC Samka
3. Ms L Moshodi
4. Mr M Khawula
5. Mr C Hattingh
6. Mrs TG Mpambo-Sibhukwana
7. Mrs L Zwane (Apology)
8. Mr D Stock (Apology)
9. Ms T Mampuru (Apology)
10. Ms D Ngwenya (Apology)
- Ms Thabile Ketye – Content Advisor
- Mr Lubabalo Sigwela – Committee Secretary (Stand-in)
- Mr Mkhululi Molo – Committee Researcher
- Ms Jeanie Le Roux – Committee Researcher
- Mr Lwazi Ben - Committee Assistant (Stand-in)
The Select Committee on Social Services (hereinafter, the Committee) conducted an oversight visit to the Free State province. The oversight visit took place during the week of 30 July to 3 August 2018.
In Free State, the Committee visited the Xhariep District Municipality and Mangaung Metropolitan Municipality. The purpose of the visit was to conduct a follow-up on the undertakings made by the Free State Health MEC in response to the recommendations made by the National Council of Provinces (NCOP) during the 2017 Taking Parliament to the People (TPTTP) programme. This was conducted by visiting specific health facilities and interacting with stakeholders which included the Free State Health Member of the Executive Council (MEC), Ms M Tsiu; Head of Department (HoD), Dr D Motau; District and Facility Managers; and personnel.
The Committee visited the following sites:
- Flora Clinic (Gariep Dam)
- Mamello Clinic (Trompsburg)
- Albert Nzula District Hospital (Trompsburg)
- Mangaung University Community Partnership Programme (MUCPP) Community Health Centre (CHC)
- Thusong Clinic
- Kagisanong Clinic
- Gabriel Dichabe Clinic
- State Garage
- Pelonomi Tertiary Hospital
The focus of the oversight visits was progress made and extent to which recommendations made by the NCOP in 2017 were implemented. The focus areas were then assessing the following:
- availability of medicines;
- availability and response time of emergency medical services;
- availability of human resources (clerks’/data capturers, porters, groundsmen, security guards, medical doctors, nurses, pharmacists and pharmacy assistants);
- staff attitude and training;
- monitoring and support to health facilities (at Local Area Manager and District Manager levels);
- waiting times;
- ideal clinic status.
This report provides an overview of these areas - highlights the findings from the sites that were visited, and reported challenges. Based on these, recommendations and issues for follow-up have been identified and made.
2.STRATEGIC FOCUS OF OVERSIGHT VISIT
In line with the National Development Plan (NDP), Medium Term Strategic Framework (MTSF), priorities of the Fifth term of Parliament, and the mandate of the Committee, the oversight undertaken in Free State focused on the public health sector.
The NDP which serves as a premise to the Committee’s plan and programme of implementation, highlights the importance of reaching a minimum standard of living for all South Africans by 2030. A key mechanism of realising this is through a holistic multi-pronged approach. In the NDP the elements of a decent standard of living include healthcare. Thus, the Committee’s oversight visit is in line with the highlighted pillars of the NDP (and as indicated previously the priorities of the Fifth term of Parliament and the mandate of the Committee).
A long and healthy life for all South Africans is Outcome/Priority 2 in the MTSF and NDP. Some of the targets geared at improving the health of the South African population include:
- Raising life expectancy to at least 70 years.
- Ensuring that the generation of under-20 year olds is largely free from HIV.
- Significantly reduce the burden of disease.
- Achieving an infant mortality rate of less than 20 deaths per 1 000 live births, and an under-5 mortality rate of less than 30 per 1 000.
- Construction of 213 clinics and community health centres, 43 hospitals; and refurbishment of over 870 health facilities in 11 national health insurance (NHI) pilot districts.
- Doubling of the number of people on ARTs from the present 2.4 million to a projected 5.1 million.
- Intensifying TB screening and treatment programmes for vulnerable groups, including 150 000 inmates of correctional services facilities, 500 000 mineworkers and an estimated 600 000 people living in mining communities.
- Vaccination of all girls in Grade 4 against the human papilloma virus, to significantly reduce their risk of acquiring cervical cancer in future.
- PROVINCIAL PERSPECTIVE
3.1 District Progress Reports
3.1.1 Xhariep District
The Committee was given an overview of progress made at the Xhariep District by the District Manager. It was reported that issues such as lack of medical equipment, dysfunctional toilets, lack of cleaning material, lack of office supplies, filling of vacant posts, medical waste removal, shortage of mobile clinics were resolved. The Department added that it procured 60 ambulances which are yet to be delivered by September 2018.
However, there were issues that were yet to be resolved such as challenges to attract and retain professionals and high turnover, slow progress on the construction of the Winnie Mandela Clinic, some of the clinics do not have adequate filing system, poor response times from the Emergency Medical Services (EMS) and shortage of ambulances, possible vandalism due to lack of 24-hour facility in the district facilities and serious water challenges which compromise the quality of care. It was further noted that slow progress on some of the activities were due to unaffordability in the current financial year.
3.1.2 Mangaung Metro
A progress report was given by the District Manager of Mangaung that since the last visit of the NCOP the following had occurred:
- The maintenance plan was developed for all the health facilities in the province, framework contractors were procured to maintain the health facilities. About 15 facilities noted as urgent by the NCOP were maintained.
- About 80 service providers were appointed and placed on the database.
- The district procured medical equipment for some of the facilities and the appointment of service provider was completed in November 2017 for the construction of Dinnane Clinic. However, approval of the business case was still outstanding (at the time of the visit).
It was noted that progress was yet to be made with regards to maintenance of some of the facilities. It was further noted that in the Westdene Clinic, the drawing for the extension were rejected by the Municipality, resulting in the delay for the extension.
3.2 Infrastructure and Financial Challenges
- Funding constraints: The Infrastructure Unit is funded by a conditional grant. Although the Department has received an unqualified audit opinion, it has high accruals, unauthorised expenditure and employment benefits backlogs partly due to not meeting supply chain management payment prescripts. The Committee was informed that the Department experienced budget cuts to the amount of R48 million during the Adjustment Budget. Approximately R18million of that was embarked for infrastructure refurbishments and maintenance.
The Committee was informed that the budget cuts placed tremendous pressure on service delivery, payment of suppliers within 30 days, and recruitment of personnel. It was further reported that this has led to inadequate allocation to non-negotiable items leading to lack of cleaning and cleaning materials and equipment, shortage of medicines, linens, hence lack of infection control and increased litigations and shortage of ambulances and vehicles.
It was reported that in spite of Treasury instruction for the Compensation of Employees to be reduced by 0,05% in 2016/17, it has been increasing and leading to crowding out of Goods and Services. The increase of Compensation of Employees was due to the need for personnel for service delivery purposes and employee benefit accruals. The vacancy rate however remained high.
- Inadequate staff: The Infrastructure Unit has 15 personnel yet it requires 67 to function optimally.
4.FINDINGS AND CHALLENGES: SITES VISITED
The Committee received briefings from the role-players and stakeholders in the form of PowerPoint presentations from the District Managers prior to undertaking site visits. The briefings were followed by discussions where the Members of Parliament (MPs) asked questions to explore and probe on issues raised (during the presentations). Further, during the site visits the Committee received briefings from the Facility Managers. These were followed by discussion and observations at the facilities.
Information presented in this report therefore comes from the information collected from presentations, discussions and observations.
The facility has a newly appointed Facility Manager, Sister Le Roux. She started at the facility in December 2017, and was allocated a Trainee (Professional) Nurse in March 2018. In addition, the staff establishment comprises of: 1 enrolled nurse, 1 assistant Nurse, 1 data clerk, 7 community health workers, and 1 cleaner.
The facility operates eight hours per day and five days a week, rendering a full primary healthcare (PHC) package. The daily headcount is approximately 18 patients. The patient waiting time rages from 30 minutes to an hour.
The Committee was informed (and shown) the two blood pressure (BP) machines and nebuliser the facility has received.
4.1.2Challenges and Issues for follow-up
- Infrastructure: The facility is very small and consists of an asbestos structure, which has negative health implications for personnel and patients. The Department reported its plans to rebuild and expand the size of the facility.
- Security: The facility has no security guard. However, a community member assists the facility whenever possible with security.
- Commuter transport and Emergency Medical Services (EMS): The facility does not have EMS attached to it. It also does not have its own vehicles. However, it was reported that it takes 45 to 75 minutes for the EMS to respond.
- Human Resource changes: The former Acting Facility Manager is no longer in the employ at Gariep Dam. However, the Local Area Manager is still employed. The District Manager reported that an investigation had been undertaken following the NCOP oversight visit in 2017, but there were no conclusive findings against the Local Area Manager. It was further reported that Supervisors are monitoring staff attitude, and a consequence management policy is in place.
The then Acting Facility Manager, Mr Moloi, has been appointed (as the Facility Manager). The staff establishment entails 6 professional nurses, 4 nursing assistants, 1 cleaner and 1 groundsman.
The facility operates eight hours per day and five days a week. The facility renders a full PHC package, and has a head count of approximately 90 patients a day.
To address the water challenges in the area, 2 Jojo water tanks were installed at the facility. The Facility Manager reported that the facility also receives water from the Municipality.
4.2.2Challenges and Issues for follow-up
- Compensation for acting positions: The Committee noted that prior to being appointed, the Facility Manager had been acting in the position for 10 years without being paid an acting allowance.
- Waiting times: It was reported that the waiting for EMS is about 80 minutes, and less than 25 minutes for file registration.
- Observations: The Committee observed that not all the ablution facilities were functional at the time of the visit. Further, the emergency exit was locked and inaccessible as there were patient files stored in front of the door. The clerks or data capturers did not have name tags. The District Manager indicated that the name tags had been ordered.
4.3Albert Nzula District Hospital
The facility has an Acting Chief Executive Officer (CEO). The Committee was informed that the facility was opened in July 2017. The services offered include: trauma, emergency and casualty; general medical ward; family planning; medical male circumcision, TB and HIV services; maternal and child services; pharmacy services; mental health services; radiology services, and allied services. The Paediatric ward, and theatre were not in usage at the time of the visit. Dental Services have not yet been offered as the hospital is awaiting the appointment of a doctor to perform the procedure.
The Acting CEO indicated that the hospital has a catchment population of 27,210 and it is projected to remain as such until 2019. It is envisioned that by December 2018 will have fully functional Out Patients Department (OPD), dental and theatre services.
It was noted that due to lack of office spaces, the Xhariep District is occupying the OPD ward. It was noted that the infrastructure budget is funded by grants as such there are no sufficient funds to complete its projects which include building office space.
It was reported that the hospital is yet to permanently appoint a CEO or Executive, community service professionals and non-negotiable critical posts such as Environmental Health Practitioners for infection prevention control, Pharmacy Assistants, Occupational Health Officer and a Data Capturer. The Department made an undertaking that all these vacant posts will be filled by the end of August 2018. The Hospital has 1 Pharmacist in its employ.
The Committee expressed concern that some of the lifts of the hospital are not working despite the hospital being new. However, the Committee was impressed with the progress on the operation of the hospital.
4.3.2Challenges and Issues for follow-up
- Human Resources: No staff have been appointed yet for rehabilitation services.
- EMS services: The Committee noted that Buthelezi ambulances have allocated space within the Albert Nzula District Hospital casualty ward. This is despite the provincial ambulances services that are located a kilometre away (adjacent) from the Hospital. There is no fleet at the facility.
- Budget constraints: There is no budget for goods and services.
- Staff accommodation: The Acting CEO reported that the staff accommodation is fully occupied by personnel. However, it is not clear whether all the occupants of the staff accommodation are hospital employees; and whether they pay a rental fee.
4.4MUCPP Community Health Centre
The facility runs for 24 hours, and has an obstetrics ambulance. The facility provides PHC services. Further it has a maternity ward which provides a full service including deliveries.
Following the NCOP visit, the facility received filing cabinets and medical equipment. Further, minor maintenance work was undertaken.
4.4.2Challenges and Issues for follow-up
The key challenges identified are as follows:
- Human Resources: There is no HR Officer at the facility. An Administration Assistant Director is assisting with HR matters, but has no training in that field.
The facility requires 8 professional nurses (lost 6 in past year), 3 Pharmacy Assistants, 1 Pharmacist, 3 Clerks or Data Capturers, 1 Medical Officer, a minimum of 4 Cleaners, porters, and maintenance workers (artisans/plumbers).
- Non-compensation of personnel in acting positions: The Department indicated that in some facilities staff is made to act in positions that do not exist as a result the Department is unable to pay them. Where a person is acting in an existing post, Persal does not allow to pay a person for acting if the person employed permanently is still being paid for their permanent position. The Committee noted that the Security Head and District Pharmacist have been acting in 7 and 11 years respectively, but received no appointment letters.
The Facility Manager reported that they provide PHC services to about 217 patients a day, and 4,032 patients a month. The staff compliments entails 8 professional nurses, 2 enrolled nurses, 4 clerks or data capturers, 1 roving assistant nurse, 2 cleaners, 2 security guards, 2 pharmacy assistants who work with 1 roving District Pharmacist. At the time of the visit there was no Pharmacist or Supervisor for the trainee Pharmacists and Pharmacy Assistants. The District Pharmacist is acting in that position.
They started a patient booking system in September 2017, however it is still work in progress.
At the time of the visit there were artisans onsite. The Facility Manager reported that since the NCOP visits, a lot of maintenance work has been done. This includes painting of the walls and demarcating/marking of parking bays. She indicated that much of the work is still in progress.
4.5.2Challenges and Issues for follow-up
- Human Resources: There is no groundsman, and only 2 cleaners. When one staff member is on leave it affects services negatively.
- Infrastructure: There was a leaking toilet at the time of the visit.
- Waiting time: the reported waiting time is 4 hours. Patients complained of spending numerous hours at the facility during the time of visit.
- EMS response time: Ambulances take too long to respond.
Following the NCOP oversight floors were replaced, ceilings were repaired and walls were painted. It was also noted that hand basins were installed. Further the Infrastructure Unit is in a process of replacing the taps.
The Committee observed that the clinic was not adequately cleaned and appealed to the District Manager to assist with procuring cleaning material and training of staff.
4.6.2Challenges and Issues for follow-up
Human Resources: The Facility Manager indicated that there is a shortage of staff.
Maintenance: Although maintenance work was done, it was not done properly. There is a burst pipe which the maintenance workers could not repair and left as is.
Filing for patient records: No filing cabinets or folders to place patient records.
4.7Gabriel Dichabe Clinic
The facility services approximately 3,200 to 4,200 on a monthly basis; and 120 to 160 patients a day.
An ablution facility for male patients has been made available by the Municipality. The facility received a new BP machine following the NCOP oversight in 2017.
4.7.2Challenges and Issues for follow-up
Key challenges at the facility include the following:
- Human resource shortage: The human resources challenges have not been addressed yet. For example, there is no security guard for the Clinic. There is no real supervision for the 2 Pharmacy Assistants. One Pharmacy Assistant will be going on study leave by the end 2018 to study nursing. There is only one toilet in the facility for females and people with disabilities.
- Infrastructure issues: There is only one entrance and no provision for an emergency exit. There is not parking for emergency medical services and staff.
- Pharmacy: The pharmacy area is not conducive. A space has been identified by the facility personnel for the pharmacy.
- EMS: There is no ambulance allocated to the facility.
- Waiting time: According to the Facility Manager it is about 2h30.
- Community Health Workers: Although they do not form part of the staff establishment, they work from 8h00 to 16h00, but do not always receive their compensation on time.
- The Free State Department of Health forwarded a request to the State Garage to procure 110 ambulances and 30 commuter/patient transport vehicles in January 2018.
- Approximately 60 ambulances have since been procured and expected for delivery on 14 September 2018.
- The HoD indicated that about 202 posts will be advertised to ensure personnel are available for ambulances. However, this will be dependent on the availability of the required skills for EMS (as this has to be in line with norms and standards).
- At the time of the visit about 10 new mobile clinics were being prepared for rural health services in the provinces. It was explained that the delay in delivery was due to the conversion and fitment of a chassis cap to carry the weight of the mobile box.
4.8.2Challenges and Issues for follow-up
- EMS: Phasing-out of the Buthelezi (private ambulances) contract, and procurement of the remaining 50 ambulances.
- Mobile clinics: The Committee was concerned about the possible cost implications of the conversions, post the purchase of the vehicles.
4.9Pelonomi Tertiary Hospital
The facility has a newly appointed CEO. She reported that since the NCOP visit the facility the following issues have been resolved since the visit:
- There has been a roll out of the electronic record management system, movable filing cabinets for the registry have been procured.
- The Department undertook to ensure that the hospital board was appointed.
- It was reported that with regards to medical equipment and consumables. This includes 6 ventilators which were procured.
4.9.2Challenges and Issues for follow-up
- Budget constraints: It was reported that there are issues that are yet to be addressed such as a roll-out plan to upgrade the hospital with timeframes and budget allocation for the upgrade project due to budget cuts.
- Infrastructure: The facility and has a linear structure, and is dated. The electrical and plumbing are outdated and requires complete overhaul. The boilers are outdated with insufficient capacity, and currently unable to provide adequate steam for heating, sterilization and hot water for cleaning and cooking.
The basement has suspended flooring, which is inadequate and results in periodic flooding whenever it rains. It is inadequate for its current usage.
Parts of the roof are leaking and the hospital experiences flooding and water damage when it rains. This also means that some patients are removed from wards and relocated when it rains. It also results in costly medical equipment being damaged.
- Human Resources: The hospital staff establishment has shrunk over time since vacant posts are frozen for extended periods and eventually removed from the organogram. The administrative staff (data capturers, clerks and messengers) has been reduced significantly over time, placing the record keeping and administrative burden on clinical staff.
- Public Private Partnerships: The Committee observed that a component of the facility’s building was being utilised by a private hospital, Netcare. In addition, there were Buthelezi ambulances at the entrance of the trauma unit.
5.DEBRIEFING SESSION: OVERVIEW OF FINDINGS
A debriefing meeting was held at the MEC’s office following the Committee’s oversight visit. At the meeting, the Committee provided an overview of the challenges that were identified and observed by the NCOP, during the Pre-visit TPTTP, which was undertaken in Xhariep District Municipality during 15 – 19 May 2017, and the Main TPTTP event, which was undertaken in Mangaung Metro during August 2017. In addition, the Committee indicated its findings and recommendations.
Overall, the Committee commended the MEC and provincial Department for the notable progress. The following were highlighted as indicative of progress:
- Infrastructural challenges: In most clinics paving has been installed, fencing is erected, there rails and ramps for people living with disabilities, medical waste storage rooms have been built, and painting has been done. However, not much has been done in terms of physical infrastructure such as refurbishment and building of new clinics.
- Grievances from personnel: The Committee Chairperson raised concern about personnel being intimidated by Senior Managers, and not being able to raise concerns openly without intimidation. The Committee made reference to the former Facility Manager of Flora Park Clinic who was dismissed following the NCOP 2017. TPTTP visit. The Committee Chairperson indicated that she received letters from personnel at Albert Nzula Hospital, who were raising concerns about management. Further, an observation was made that there is a leaking roof at the hospital’s casualty ward.
- Human Resources: Most Facility Managers who were acting are now employed fulltime. However, the issue that is remaining is the payment of acting allowances. Most of the Facility Managers (and other job categories) were acting for more than five years without being paid acting allowances.
- Medical equipment: Most clinics received medical equipment in both Mangaung and Xhariep. However, there are clinics that are still waiting to receive their medical equipment.
- Communication systems: Some of the clinics have internet connection and mobile phones have been procured. Some clinics do not have files for patient records and inadequate filing cabinets. The Department reported that they are moving to a new filing system, which will commence at the end of August, or beginning of September 2018.
- EMS and patient transport: The Department reported that they have procured 60 ambulances that will be kept at the State Garage. This is in order to reduce the ambulance response time and replace the old ambulances. The Department also reported that they have acquired commuter buses and mobile clinics.
- Availability of medicine: There are great improvements in the availability of medicines across the sub-districts with the availability rates as high as 98% -100%.
- Security: Some clinics have received additional security personnel while others are still without security personnel. Some clinics do not have alarm systems. In one clinic, the alarm has been deactivated due to non-payment.
The MEC indicated that her office also undertook an investigation and found that the former Acting Facility Manager was unfairly dismissed. She indicated that the former Acting Facility Manager would be reappointed in Mangaung. The Department thanked the Committee and took an undertaking to address most concerns raised by the Committee before the end of August 2018.
The Committee made the following recommendations:
- The Free State Department of Health should:
- Assist with training personnel and recruiting to alleviate waiting times and adjust staff attitudes. Further, the Department should invest on, and encourage team building sessions at district, local area and facility levels to improve cordiality among personnel and patients.
- Prioritise rural health services. Provide a detailed report to the NCOP and the Committee of its contract with Buthelezi ambulances. Further, the Department should negotiate delivery of some of the ambulances before the end of August 2018 (with its service provider). The Committee will hold a briefing with all the EMS operators on 27 August 2018.
- Ensure that policy requirements are met when appointing acting personnel. The Human Resources Unit should conduct an audit of personnel who have been in acting positions, engage with affected personnel, and find remedies with Managers on how to compensate personnel that had been appointed in acting positions. The audit report must be made available to the Committee.
- Look into how to address community health care worker challenges. Adherence clubs should be supported as they are doing a good job in the communities.
- Prioritise the appointment of Senior Management at Albert Nzula Hospital and fast track compulsory induction programme for all staff and allocate cars for the hospital.
- Provide a report on the contractual agreement between Pelenomi Hospital and the Private Hospital that is using a section of the facility. This report must be provided to the Committee. Further, The Department should ensure that Pelonomi Hospital has its own organogram with a full staff complement. In addition, the recruitment and employment of professional nurses should be prioritized especially those who are skilled in the operating theatre.
- Reassign the Local Area Manager from Gariep Dam/Kopanong to another area.
- Strengthen its monitoring and evaluation systems. The Infrastructure Unit should monitor the projects under construction until completion; and liaise with the national Department of Health regarding infrastructure projects, and norms and standards thereof.
- Equipment and medical consumables should be budgeted for and procured at district level. The budget of Albert Nzula District Hospital should speak to the short, mid, and long-term plans. Further, Facility Managers should be involved in budgets of their facilities
The Committee undertook oversight on the Free State Department of Health, following recommendations by the NCOP during its 2017 Taking Parliament to the People programme.
The sites were visited with various stakeholders and role-players, and provincial Departmental officials. Following this, a debriefing meeting was held at the MEC’s office. This proved to be a fruitful exercise as it enabled the stakeholders and role-players to see and understand progress made in relation to the projects.
The Committee deliberated and concluded that in the main there was commendable progress since the NCOP visit in 2017. This includes procurement of mobile clinics, ambulances; projected plans for placing security guards at the health facilities; installation of air conditioners, ensuring there is adequate medical equipment and consumables. However, the Committee also noted that some of the maintenance work was being done during the oversight visit. This can be regarded as implying that work was being done in anticipation of the oversight visit.
The Committee, however noted the following as crucial in strengthening the projects visited:
- The importance of taking into account policy implications during the planning phase of projects.
- The need for strengthened inter-governmental relations and thus better coordinated collaboration.
- Comprehensive monitoring and reporting of progress.
- The improvements should not only apply at the health facilities that were visited by the Committee (as this was a sample), but throughout the province.
Following this undertaking, the Committee will undertake a follow-up visit at Pelonomi Hospital on 27 August 2018. Further, the NCOP through its Taking Parliament to the People Programme will undertake oversight in Free State between 27 and 31 August 2018.
Report to be considered
 Initially the Committee was to visit Itumeleng or Fauresmith Clinic. However, a decision was taken to conduct an unannounced oversight visit at Mamello Clinic.
 Are employed by non-governmental organisations (NGOs) that are outsourced by the Department to run adherence clubs, and provide support to patients.
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