ATC230209: Report of the Portfolio Committee on Health on an oversight visit to the Eastern Cape Province from 4 to 6 November 2022, dated 02 December 2022

Health

Report of the Portfolio Committee on Health on an oversight visit to the Eastern Cape Province from 4 to 6 November 2022, dated 02 December 2022

The Portfolio Committee on Health (the Committee) having undertaken an oversight visit to Gqeberha, Nelson Mandela Bay, Eastern Cape Province, on 4 to 6 November 2022, reports as follows:

Purpose of the visit

One of the roles of Parliamentary Committees is to ensure that government is accountable at all times, by conducting oversight, particularly on the ground to ensure that service delivery takes place as per the legislation.

The Committee’s visit was premised upon reports on challenges health care facilities in the province are facing, including the Public Protector’s report into allegations of worsening conditions within health care facilities in the Eastern Cape. The reported challenges included the following, amongst others:

New-born babies that died in overcrowded and understaffed wards;
Waste material in the corridors of a hospital, dirty laundry and boxes marked “danger infectious waste” lie in passages;
Facilities do not have enough ambulances;
Staff shortages which means that one nurse has to take care of 50 patients;
Water shortages at facilities;
Unhygienic conditions are prevalent at facilities; and
Nurses being forced to act as cleaners in some instances and security guards often forced to cover up for absent medical staff and carry patients into causality.

Subsequent to the investigation of the Public Protector, a report was released with findings covering a range of matters, inclusive of recommendations. The Health Ombud also visited the same health facilities to assess progress made in implementing the Public Protector’s recommendations.

On 12 October 2022, the Health Ombud briefed the Committee on the office’s annual report for 2021/22 and recommended that the Committee visit the health facilities to assess progress made as the conditions were bad.

Delegation

The delegation comprised of the following Members of Parliament:

Dr KL Jacobs (ANC) – Chairperson of the Committee
Mr T Munyai (ANC)
Ms A Gela (ANC)
Dr X Havard (ANC)
Mr NVX Xaba (ANC)
Mr EK Siwela (ANC)
Ms M Clarke (DA)
Ms ERL Wilson (DA)
Dr SS Thembekwayo (EFF)
Mr P Van Staden (FF Plus)

Parliamentary Officials that accompanied the delegation:

Ms Vuyokazi Majalamba (Committee Secretary)
Ms Vuyokazi Makubalo (Committee Assistant)
Ms Lindokuhle Ngomane (Content Advisor)
Mr Moses Mncwabe (Committee Researcher)
Mr Zubair Rahim (Committee Researcher)
Mr Mava Lukani (Communication Officer)

Officials from the National Department of Health:

Mr Joe Kgatla: Parliamentary Liaising Officer (PLO) in the office of the Minister
Ms Keneilwe Modise: Hospital Management
Ms Anne Jautse: Quality Assurance
Mr Sam Bakhane: Health Technology
Dr Miriam Matandela: Nursing

Sites Visited

The Committee visited the following health facilities in the Eastern Cape:

Uitenhage Provincial Hospital;
Dora Nginza Regional Hospital;
Livingstone Tertiary Hospital; and
Port Elizabeth Provincial Hospital.

3.1.Uitenhage Provincial Hospital

On the 4th of November 2022, the Committee visited Uitenhage Provincial Hospital (UPH) and held a meeting with the provincial health officials, district management team, UPH management, health professionals, hospital board members and unions.

Presentation by the hospital management

The Acting Chief Executive Officer (CEO), Ms N Hoffman, made a presentation to the Committee and indicated that Uitenhage hospital is a 238 bed district hospital in Sub-District B. The population of Sub-District B is 307 629 with 217 186 uninsured (70.6%). The Acting CEO further briefed the Committee on bed utilisation per department.

The Acting CEO updated the Committee on the status of appointments at the facility. On challenges and actions taken, the Acting CEO indicated that there were delays in filling of non-clinical positions and that they are waiting for approval from the head office. The facility does not have a quality assurance manager and that a request for reactivation of the post has been submitted to head office. On lifts on the main landing, two have already been upgraded and are waiting for OTIS to connect and that one is due for an upgrade in the next financial year.

Autoclaves have been reported to Provincial Infrastructure for assistance as they have been continuously giving problems. It was further noted that gangsters are posing a challenge to the safety of the staff and that access control and guards allocation has been strengthened and additional cameras installed. Patient records mismanagement and insufficient filing space remains a challenge. The facility has commenced with weeding and organised a lockable garage to create space. The proper use of HMS2 digital platform has also been encouraged to avoid duplicate files.

On achievements, the Acting CEO reported the following:

Appointment of clinical personnel and nine general workers.
The facility has also received a support visit from the District TB and HIV management teams together with Match to encourage data management and link to care.
The hospital board was inducted in August.

The Acting CEO further briefed the Committee on the feedback on the Public Protector’s report. On additional vehicles, so far the hospital manages to prioritise all needy transport activities (not fully complying). One vehicle is used to facilitate communication between the facility and the district and the other is used to facilitate operational requirements like emergency National Health Laboratory Services (NHLS) duties. She highlighted that a bakkie is needed to transport large amounts of stock from the depot stores as they were currently using one from Osmond Hospital. It was noted that the current vehicles are not sufficient for the current usage in the hospital and that there is a need for one extra sedan and one bakkie.

On issues observed in the high care unit, it was indicated that the hospital is compliant and that the high care unit was fully equipped ever since it started functioning. All oxygen points were fixed in the wards and in the trauma unit.

On staff accommodation, it was highlighted that the doctors’ residence was upgraded in 2016 (repainting, doors and electrical). All flats were fitted with security gates and burglar bars in 2018. It was indicated that the challenge was with the nurses’ home, the building was damaged by a leaking reservoir in the roof. Community service nurses are accommodated in the doctors’ quarters, when space is available. Due to budgetary constraints, the repair and refurbishment of the nurses’ home could not be funded and will be included as part of the health professional’s accommodation project of the Department. (Presentations are available on request to the Committee Secretary).

Committee observations

The Committee conducted a walk-about at the Uitenhage Provincial Hospital and observed the following:

Casualty:

Small and overcrowded, with poor ventilation.
Untidy with boxes stored next to patients’ beds
Medicines were not properly stored.
There was no patient privacy, patients were examined without curtains being drawn.
The emergency unit was overcrowded, with limited space. The nursing station was disorganised.
The resuscitation room is very small, a 3-bedded unit. Adults, children and neonates are resuscitated in the same room. Additional space is being prepared for isolation of paediatrics and neonates.
The waiting area is small with poor ventilation. Members of the Committee interacted with patients who complained about the long waiting times, and that at times, it takes a day to be attended to. There was a patient who was lying on the bench since the previous day who was very ill and dehydrated without having a drip up and had not been attended to.
The triage room had a shortage of linen; infection control guidelines are not adhered to.
The trauma consultation room was understaffed, as reported. There was only one trauma trained nurse/specialist trauma nurse and only one trauma unit operations manager who only worked night duty. Infection control and prevention was lacking.

Theatres:

Two of out of three theatres were functional, staffing shortages is the major challenge.
Shortage of cleaning materials was reported.
Autoclaving is a challenge, which has a major impact as surgeries could not take place as scheduled. Only one autoclave is working.
Porters have not received uniforms in four years, making them unidentifiable as they wear casual clothes.

Neonatal theatre:

There were three nurses working at the theatre who were not theatre-trained.

High care theatre:

A 5-bedded unit with separate neonatal high care.
The theatre was neat and tidy.

Neonatal ICU:

Ventilation was not adequate.

Mental health unit:

Although bed linen was provided, patients were using their own blankets.

Kitchen:

It appeared clean and neat.
It was reported that there was a three-year food supply contract in place, however, the supplier has not been supplying fish and chicken livers.
Expiry dates on food items were missing.
Fridge storage capacity needs to be assessed.
The kitchen sink is leaking
The roof is also leaking.

Mortuary:

Members of the Committee observed a walk-in mortuary cold-room which was donated to the hospital by Volkswagen motor company.
There is severe understaffing in the hospital mortuary itself, with one official working as a porter, cleaner and administrator, with no acting allowance.

Laundry:

It is small with three machines.
Laundry at the hospital is outsourced, only theatre laundry was being cleaned by the in-house laundry.
It was reported that all the machines are due to be replaced with 5-year maintenance plans included.

Generator:

There is a large diesel generator, which can provide power to 80% of the hospital.
The hospital is now exempt from load-shedding.

Staffing:

There is a shortage of trained nurses, and non-clinical staff such as cleaners.

Infrastructure and maintenance:

There are beds and linen shortages at the facility.
The beds and medical equipment are old.
Ventilation was poor throughout the hospital.
The functioning lifts were in poor condition, as the ceiling panels were damaged and dirty and the floor was damaged.

Dora Nginza Regional Hospital

The Committee proceeded to Dora Nginza Regional Hospital (DNRH). The Committee met with the provincial health officials, district management team, hospital management, health professionals and members of the unions.

Presentation by the hospital management

The CEO made a presentation to the Committee and indicated that Dora Nginza is a regional hospital located in sub-district A of Nelson Mandela Bay Health District. It is a 627 bedded facility but there are 596 usable beds. Services offered at the facility includes; Emergency Medicine, Internal Medicine, Psychiatry, Obstetrics and Gynaecology, Paediatrics and Neonatology, Surgery, Anaesthesia, Orthopaedics, a Burns unit and a Thuthuzela Care Centre.

Pressures on maternity, neonatal and paediatric services at the facilities were highlighted as follows:

The ever increasing demand on maternity and neonatal services far outweighs the physical and human resources available, which leads to:

Pregnant women having to sleep on chairs and on mattresses;
Excessively long caesarean section waiting lists with patients waiting several days in order to get access to an elective caesarean section. There are on average 10 to 30 patients on the waiting list on a daily basis. DNRH is the only facility where caesarean sections are performed for the entire Western region. This contributes to adverse outcomes and increased perinatal mortality rates;
Maternity cases already overflow to PE Provincial Hospital with 16 beds available;
Severe overcrowding in the neonatal units with a high bed utilisation rate. This leads to increased mortality due to hospital acquired infections;
The DNRH Paediatric ICU serves as the only ICU for all children in the Western region;
The Paediatric ICU has only six beds and these beds must cater for all children with both medical and surgical conditions in need of the ICU care;
On average, every week, two children or infants in need of ICU care are unable to access such services due to all six beds being occupied;
There are also no paediatric high care beds that can alleviate the pressure on the Paediatric ICU; and
Sometimes patients have to be sent to private facilities as a last resort to save lives.

The plans to decrease the pressure on maternity, neonatal and paediatric services at DNRH were outlined as follows:

The movement of tertiary maternity, neonatal and paediatric services to Livingstone Tertiary Hospital (LTH). It was further noted that DNRH is also expected to take over surgery and orthopaedic services from LTH as per the gazetted service package of a regional hospital;
Establishment of a district hospital in the metro that can perform level one caesarean sections; and
Increasing the number of Paediatric ICU beds to ten (infrastructure and equipment already available at DNRH, staff is needed).

Challenges at the facility were highlighted as follows:

Access control at the gate:

Gates must be moved and replaced, boom and pedestrian access gates must also be added.
Speed humps are needed to slow down traffic approaching the gate.

Guardhouse:

The guardhouse is incorrectly placed and it should be behind the security gates
There are no ablution facilities for the guards.

Perimeter fencing:

Gaps in the Spondo Street fence provide uncontrolled access to criminals and livestock and domestic animals.

CCTV system:

CCTV system moved from the field hospital to DNRH. Installation of the new system with 74 cameras is almost completed.

Traffic control from Spondo Street:

Increased traffic and accident risk at the entrance from Spondo Street. The Municipality has been engaged for a construction of a traffic circle with no response.
EMS response time is also affected as they get dispatched from the EMS base at DNRH.

Roof leakages:

There are extensive leakages of the roof in the whole hospital.

Frequent closure of CHCs:

Increased patient load on an already overstretched system at DNH Maternity and Accident & Emergency.

Laundry services:

DNRH laundry not attended to at LTH. Small in-house laundry opened but not able to cope with the needs of the entire hospital.

Shortage of Mental Health beds in the metro:

There is a frequent challenge of unavailability of beds for mentally ill patients resulting in them being nursed on stretchers for several days.

Finances:

Medico-legal claims - funds used to settle claims are taken from the facilities’ budget without consultation.
Accruals cause a deficit on the facilities’ budget every year.

Unreliable water supply from the municipality.
Staffing:

Non appointment of non-clinical staff such as cleaners, porters and laundry workers since 2018.
Restrictive recruitment processes continue to create frustration and the HOD has been asked to look at their unintended consequences.

An updated situational analysis was presented as follows:

DNRH was able to absorb most of the clinical Covid-19 contract workers into replacement positions.
A separate presentation by the Human Resources Manager reported on current recruitment achieved in the last three weeks and still in progress.
A budget of R38 million has been approved for infrastructure over the next three years. These funds will prioritise the building of a new 72-hour unit and casualty but also cater for fencing, roof, repairs, security gate repairs amongst other things. First meeting with all stakeholders to determine priorities was held on the 3rd November 2022.
The 72-hour ward was relocated in October 2022 to one of the empty wards previously occupied as medical wards. This was done due to staff complaints about unhygienic and inhuman environment caused by limited patient ablution facilities and no isolation rooms.
Since 8th October 2022, there has been no patient nursed on chairs and mattresses. This follows the intervention of the HOD after staff embarked on an industrial action.
Sixteen beds have been made available at Port Elizabeth Provincial Hospital to cater for maternity overflow which is managed on a daily basis due to its fluidity

Committee observations

The Committee conducted a walk-about at Dora Nginza Regional Hospital and observed the following:

Casualty:

This section was in poor condition. The ceilings and walls showed evidence of extensive water damage.
There is a shortage of medical equipment and staff. The two examination beds and three trolley beds are inadequate.
The unit sees on average 20 to 30 patients per day, and the average waiting time can be more than 3 hours when busy.
Cleanliness was poor in the casualty ward.
The resuscitation room is very small, poorly equipped and not conducive to its purpose.

Maternity ward:

A 40-bedded unit, which was renovated through the Bill Clinton Foundation.
The caesarean section ward had only one bed available; emphasizing the shortage of beds.
Toilets were very unhygienic.
Members of the Committee observed that patients’ records were not stored properly.
The presence of young pregnant girls at the maternity wards was noted with concern.

Labour ward:

There are three delivery rooms.
The theatre was not functional due to staff shortages.

Antenatal wards:

There were reported bed shortages.
Staff shortages were also reported, with wards functioning with two professional nurses per shift.
Patients use their own blankets.

Postnatal wards:

Two wards with 30 beds each.
Shortages of beds are a major constraint, only 3 beds available for post-caesarean sections.

Neonatal ICU:

A 6-bedded unit. The beds are inadequate.
The unit needs to be expanded, however, staff shortages is a major challenge.
Current nursing staff are not trained in neonatal care.
There are no neonatologists in the hospital.
Members of the Committee appreciated the commitment and dedication of the staff, but also noted the lack of training opportunities.

Paediatric ICU:

There are severe bed and staff shortages.
There is space to accommodate ten beds, but due to staff shortages, the expansion is not possible. Due to these challenges, children who require ICU are sent to the general ward.

Paediatric ward:

A 40-bedded unit that sometimes increases to 70 beds. The overcrowding could lead to infection outbreaks.
The unit operates with only two professional nurses.

L-block Clinic:

This clinic provides specialist dermatological care, treating skin and other conditions. It is attended by a specialist daily.

Laundry:

There is no proper space for laundry services; laundry is sorted in front of the lifts.

Human resources - support services:

There is only one official responsible for laundry, kitchen, security, cleaning and garden, due to staff shortages.

Mortuary:

The mortuary was closed due to staff shortages.

Infrastructure and maintenance:

The facilities’ infrastructure was in a poor condition. Members of the Committee were concerned that it was an occupational health and safety hazard.

Mental health unit:

A 35-bedded unit, with four (4) seclusion rooms.
The CCTV system was not working and is reportedly a common occurrence. This is a huge safety risk for the staff, as patients are not properly monitored from the central area.
Maintenance and infrastructure are a huge concern. The unit was built in 2015 but it was not safe for patients and staff and it had cracks and it looked like it can collapse.
There is a shortage of professional nurses with psychiatry training and advanced psychiatric nurses. The staff reported the lack of training opportunities.

72-hour observation unit:

The hospital is currently converting a general ward into a 72-hour observation ward.

Kitchen:

Staff has no protective clothing.
There was no hot water at the kitchen on the day of the visit.
The oven and electric pots were not functioning.
There is a shortage of staff. Cleaners have not been appointed since 2018.

Records:

It was reported that patients generally wait from 6:30 am to around 11:00 am for their files.

Pharmacy:

The pharmacy serves clinics in the surrounding area.
Stock availability was at 95% and the hospital share with other hospitals as needed and vice versa.

General:

The hospital, in general, was very dirty and unkempt.
There is a lack of maintenance and cleaning, attributed to the moratorium on the appointment of non-clinical staff.
Toilets used by patients were described as disgusting by members of the Committee.
The perimeter fence is broken.
Nursing home is a 7-floor building. There are often water and electricity outages, and at times, nurses have to carry buckets of water up the stairs.

Livingstone Hospital

The Committee conducted an oversight at Livingstone Hospital on the 5th November 2022. The Committee met with the provincial health officials, district management team, UPH management, health professionals, hospital board members and unions.

Presentation by the hospital management

The Acting CEO presented to the Committee and highlighted that the facility has been affected by Covid-19 and that there was a governance collapse. He further indicated that the staff morale has been negatively affected by Covid-19.

The Acting CEO noted that they have not received any support post-Covid-19. He indicated that the hospital is faced with severe staff shortages and that maintenance is very poor. They rely too much on outsourcing. He highlighted that since 2018 there has never been replacements of non-clinical staff. Safety and security was noted as a big issue.

The Acting CEO noted that Livingstone has not completed the decomplexing process. They have a budget of R1.4 billion and they have 400 unfunded beds. The budget is shared with Port Elizabeth Provincial Hospital because the latter does not have its own budget. He further highlighted that the facility is a tertiary hospital but they cannot chase away walk ins by local patients.

Committee observations

The Committee conducted a walk-about at Livingstone Tertiary Hospital and observed the following:

ICU:

The 16 bedded-unit is not adequate.
There are severe staff shortages at the ICU, to a point that patients would skip their doses of medication.
One nurse attends to 15 patients. There are 4 doctors, who often push patients due to the shortage of porters.
There is no head of department.

Theatres:

The functional theatres are not adequate.
Eight out ten are functional; two (Accident and Emergency theatres) are being renovated.
The two Accident and Emergency theatres were not functioning due to being non-compliant with fire detection regulations, as well as having access control issues.

Oncology department:

Oncology machines were not working and requires about R100 million to repair.
This has a severe impact on oncology treatment in the province.

Orthopaedic

There is a shortage of implants. Patients waiting times are two to three weeks for implants.
Currently, there are 100 trauma orthopaedic patients on the waiting list.

Renal unit:

There are three (3) renal units, with eight patients undergoing haemodialysis.
Patient transportation is a challenge.

Medical wards:

There are two male and female medical wards, 45-beds each.
The sluice room was in a terrible condition.
Some windows in the female ward are suicide proof, following suicide incidents.
Patients use their own blankets.
Members of the Committee noted that patients’ privacy and dignity was not respected.

Medical equipment:

The CT scan has not been functional since 2018.

Stores, water tank and diesel storage:

There was a 300 000 litre water tank donated by the non-governmental organisation (NGO) Gift of the Givers. They had also drilled a 220 metre borehole and provided the pipes to connect to the water tank.
Another large capacity water tank was located nearby.
A contract had been signed to fence in the water tanks, as well as a nearby wetland area on the hospital grounds.
The diesel tank can hold 20 000 litres of diesel and was currently 90% full. The hospital is currently exempt from load-shedding.
The Committee was informed that the budget for boiler fuel was depleted. This had an impact on linen and thus surgeries.
The engine has no oil and they had to wait for eight weeks to get the oil.

Kitchen:

There are severe staff shortages. There are 13 food service workers who cater to 700 patients.
There are no cleaners. The cooking staff also have to clean the kitchen and working areas.
Equipment is old.
Two pots are not functioning properly, which poses a huge occupational health hazard to the staff.
Food trolleys are old.
Food warmers are not working.
Staff has no protective clothing.
The automated kitchen system project has stalled due to lack of funding.

Mortuary:

The mortuary has a capacity of 69.
It appeared clean but smelly. The Committee was informed that there are 28 unclaimed bodies, which had been there for more than six months. SAPS have been notified, however they are taking too long to respond.

Laundry:

At least two machines were broken at the time of the visit.
The staff reported that the availability of linen is improving, there are fewer complaints.
Two autoclaves were not working.

The acting manager in the laundry is also responsible for cleaning, security, food services and waste.
Staff at the laundry were last issued uniforms or protective clothing in 2020.

Infrastructure and maintenance:

Toilets are leaking. There was the smell of urine in the passages and in the wards.
Lifts were not working in the P-block which housed the paediatric unit.
Maintenance of the facility has not been attended for many years.

Staffing:

The hospital does not have a Facilities manager.
There are 14 vacant posts of operational managers.
People who are in acting positions are not compensated.
Clinicians highlighted the instability in leadership at the facility.
The Committee noted with concern that the accommodation of the Acting CEO at Livingstone Hospital is being paid by the Department.

Safety and security:

Security is poor, doors are unlocked.
There are people who bathe at the back of the facility.
The hospital toilets have been vandalised, flush plates and taps were stolen.

Records:

Hospital records are not properly filed; they are kept all over the hospital.

General:

The hospital is unhygienic; an infection control risk.
Medical waste has not been collected and was not properly stored.
Beds are stored everywhere, outside and also in passages next to the lifts.
Concern was raised about staff members who wear union t-shirts to work and not uniforms.

Port Elizabeth Provincial Hospital

The Committee did not receive a formal presentation at the PE Provincial Hospital as the hospital is housed under the Livingstone Hospital.

Committee observations

The Committee conducted a walk-about at the PE Provincial Hospital and observed the following:

Cathlab and theatre:

The unit was very clean and neat.
It is the only one in the western region that performs open heart surgery.
On average, they see 5 patients per week.
They are faced with procurement challenges to replace valves for the heart.
There are staff shortages. There is no full time medical staff after hours.

Temporary ICU:

A 6-bedded unit (5 useable) which is shared between adults and children.
The unit is undergoing renovations.
There are no doctors on call.

Paediatric oncology:

A 12-bedded unit.
The unit was clean, with proper ventilation.

ENT unit:

Poor lighting in one of the wards and black mould on the walls.
The windows were very dirty.
Bathrooms were in poor condition.
There were no curtains between beds.
The ENT theatre does not have a theatre light.

Records

The records section was housed in a very old building. There was evidence of water damage.
The Committee members were concerned that the filing system was not effective. In a small room, there were boxes of files piled up high in a very dirty room.
There is no system to manage medical records.

Pharmacy:

Availability of medicines was of great concern. Due to non-payment, suppliers were opting not to supply medicines. For instance, Sinofi was another critical supplier which will likely close its account.
Whilst small, the pharmacy was neat and tidy. Medicines were well-organised and laid out.
The air conditioner was broken, and medicines need to be kept at a cool temperature. This has been broken since April and the facility staff struggled to obtain an order number from head office for a service provider to come out to fix it.

Psychiatry:

The hospital has a 72-hour observation unit. It houses 18 male and 18 female patients. Whilst patients are supposed to spend 72 hours, they can spend up to 2 months waiting for a bed in Elizabeth Donkin Hospital.
There is a shortage of adolescent psychiatrists and units, this as the number of adolescent patients has increased.

Water storage:

A large water tanker/bladder was observed. This was donated by the Gift of the Givers.
Works were busy providing fencing and shading around the water tank. The Gift of the Givers had provided a borehole at this hospital as well.

Linen section:

Committee members were impressed as it appeared neat and generally clean.
Laundry was outsourced to a company.
Previously, linen was sent to Livingstone Hospital, but there were issues with poor service delivery.

Nurses’ home:

The old nurses home was dilapidated and in terrible condition. The Committee was informed that it was prone to vagrants and theft. There were many broken windows.
The building nearby was the current nurses home. This building, too, looked in poor condition with visible water damage, peeling paint and general state of disrepair.

Infrastructure and maintenance:

The infrastructure is dilapidated, in poor condition, lacks maintenance and needs to be refurbished.
The air conditioner was not functioning, poor ventilation.
There was no electrical, plumbing, building or supervisory staff at the hospital. There was at most 1 carpenter, and 2 painters.

Meeting with the MEC and senior officials of the Department

Having concluded the oversight, the Committee met with the MEC for Health, Ms Nomakhosazana Meth, the HoD, Dr Rolene Wagner and other senior officials of the Department, and highlighted the following observations and findings:

Financial Issues: Budget cuts: facilities are unable to deliver optimal services due to financial constraints. Accruals and medico legal claims are depleting the facilities’ budgets.

Governance: With respect to Livingstone and Port Elizabeth Provincial Hospitals, the key challenge is the complexing, which makes it impossible to ensure governance of the two facilities. Both facilities are managed by one CEO which is a challenge.

Human resources: Staff shortages is a major challenge across all visited facilities, both clinical and non-clinical staff. Appointment of non-clinical posts was last done in 2018.
Infrastructure: The Committee expressed concern on the state of infrastructure in all visited facilities. Maintenance is not done in all visited facilities. The infrastructure is dilapidated with leaks and the walls are peeling off. There is a general lack of space, overcrowding and lack of privacy. Dora Nginza Mental Health Unit was built in 2015 but it is on the brink of collapse as there are cracks in the walls.
Cleanliness: All visited facilities were very unhygienic except for some units at Port Elizabeth Provincial Hospital.
Laundry services: The laundry services are not properly functioning in all visited facilities.

Safety and security: Uitenhage Hospital, Dora Nginza and Livingstone Hospitals reported safety concerns in the facilities. People fight outside the hospital and they take their fights inside the hospital. This poses a safety concern for staff working at these facilities and patients.
In conclusion: Despite the aforementioned observations, the Committee was impressed with the level of commitment from the management and officials in these facilities. The conditions in which they work are extremely depressing yet they exhibit compassion to the health users who depend on them for services.

MEC’s Remarks

The MEC provided a political overview and indicated that the Department has done a diagnostic analysis of the problem and that they have put measures in place to ensure that they turn the corner. The department has since adopted a turnaround strategy with five pillars:

Financial Sustainability
Integrated Medico-Legal Strategy
Service Delivery Optimisation
Digitalisation and e-health
Building Healthy Communities

4.1.1.Medico-legal claims

The MEC further highlighted that in the previous financial year, the Department paid more than R920-million to litigants. However, during the 2021/22 financial year, the Department managed to pay R44-million based on a three pronged approach.

Department focused on the implementation of the Integrated Medico-Legal Strategy, ensuring interventions focusing on administrative, clinical and defense capacities are put in place. This is also complemented by the support from both Office of the Premier and the Provincial Treasury.
The Department received assistance from the Office of the Premier, SIU and the Provincial Treasury because if not stopped, medico-legal claims could bring the whole administration to its knees.
The Department also purchased three specialised custom-made vehicles to accommodate cerebral palsy children, caregivers and wheelchairs in the management of cerebral palsy at Nelson Mandela Academic Hospital, Dora Nginza Hospital and Cecilia Makiwane Hospital.

In strengthening of legal services, the MEC highlighted the following:

The department has decided to projectize management of medico-legal, including strengthening of in-house Legal Services. Provincial Treasury has granted R5-million as a response to the need to strengthen capabilities of Health, as a result Chief Director: Legal Services has been appointed on a 1-year contract. Additional 20 posts will be advertised this week, this includes, clerical and legal staff.
Process for selection of 5 Legal Advisors and Senior Manager replacement are also underway and the incumbents might assume duty in January 2023.
Whilst the Chief Director, as part of the 21 posts, will be focusing broadly on Legal Services including medico-legal, others will focus purely on medico-legal including credibility of database, contingent liability management and PAIA coordination.

PAIA Management

The department has centralised the PAIA application process to ensure that all files requested are scrutinised and also digitalised and stored electronically in the e-PAIA system as a request for a record is always an indication of litigation in waiting.

What is also critical is the ability of the department to engage with the submitted files to ensure that issues that are picked up are addressed, as each file carries information on the patient and what is likely to be challenged.

Mental health

The MEC indicated that mental health is also receiving responsiveness from the 6th administration. Just last month, the MEC officially launched a state-of-the-art adolescent and child unit at Fort England Hospital in Makhanda at a cost of R29 million. The Mental Health Directorate has successfully organised mental health day on the 13 October 2022 at Makhanda sub- district wherein about 500 community members were in attendance to listen to mental health messages. St Barnabas, a state of the art 33 beds mental health unit is being finalised and will be handed over to the department by March 2023.

The province will be strengthening the community based mental service especially in rural areas by employing 31 registered counsellors that will primarily focus on mental illness prevention programmes for individuals and communities. These officials are currently being recruited and the majority of them will be appointed by the end of October 2022. The department is in the process of building human resources capacity and as a result has conducted interviews for general workers, administration, finance, human resources, nursing managers, professional nurses, psychologists, social workers, occupational therapist and Child Psychiatrists. Some of these official have already assumed duty. These the efforts to build the capacity of mental health institutions of Fort England, Tower, Komani and Elizabeth Donkin hospitals. In September, the province appointed mental health review boards which are clustered per district and they have been inducted to carry out their work without fear or favour so as to improve mental health services.

4.1.4.Recommendations of the Health Ombud

The MEC further noted that the department has implemented most of the Ombudsman’s recommendations at Tower Mental and Rehabilitation unit regarding the taking of disciplinary measures against all affected individuals, rectification of systemic challenges, such as the non-availability of the Director for Mental Health at Head Office, the lack of necessary protocols and repairing of minor infrastructure challenges. The Department is in the process of resolving the challenges of infrastructure, such as perimeter fencing and proper portioning of the kitchen.

Presentation by the HOD

The HOD presented plans to address issues that the Eastern Cape Provincial Department of Health is facing and the timeframes thereof. The HOD highlighted the following as objectives of the infrastructure plans:

Create conducive health facilities’ spaces which accommodates all staff and clients, all clinical and support services areas to ensure the rendering of quality services in the short, medium, and long term in terms of the Service Delivery Model of the Health Department.
Make all buildings compliant with safety regulations.
Deliver approved building plans for all buildings and obtain Occupation Certificates for all buildings.

The short, medium and long-term infrastructure plans for Nelson Mandela Bay Hospitals were as follows:

The hospitals earmarked to undergo Infrastructure improvements, alterations and additions over the MTEF are:

Dora Nginza Hospital (R36 million);
Livingstone Hospital (R14 million);
PE Provincial Hospital (R14 million – current budget, to be reviewed);
Empilweni Hospital – conversion to a District Hospital (R31 million);
Jose Pearson TB Hospital (R12 million); and
Uitenhage Provincial Hospital (R6 million- to be considered for inclusion in final budget submission) – Improvements to Casualty and Doctors accommodation.

The projects are at initiation stage. The planned milestones include the finalization of designs and procurement of contractors in year 1 and construction and commissioning in years 2 and 3.

Primary healthcare facilities earmarked to undergo infrastructure improvements, alterations and additions over the MTEF are:

Kwazakhele CHC (R38 million);
Central Clinic/CHC Sandford (R 15 million);
Motherwell CHC (R32,2 million);
Gqeberha CHC (R3 million);
Forensic Pathology Centers (R1 million);
Community Health Facilities – Sub-District A (R6 million) NU 11 Clinic, Lunga Kobese Clinic, Veeplaas Clinic, Soweto Clinic, Max Madlongozi Clinic;
Community Health Facilities – Sub-District B (R6 million) Rosedale CHC, Gustav Lamour Clinic, Park Centre Clinic, Middle Street Clinic, Silvertown Clinic (Kwanobuhle); and
Community Health Facilities – Sub-District C (R6 million) Booysens Park Clinic, Govan Mbeki Clinic, Algoa Park Clinic, Helenvale Clinic, Kwadesi Clinic.

The HOD reported the following steps that the Department has taken to secure budget for the three major infrastructure projects:

The Department initiated the process of undertaking the implementation of three (3) major infrastructure improvement projects at Livingstone Hospital, Dora Nginza Hospital and PE Provincial Hospital so that all the Tertiary Services can be accommodated more effectively, preferably all at one location and improve functionality in terms of the service delivery model.
The HOD wrote to the National Department of Health Director-General, Dr Buthelezi on 11 October 2022, requesting that these three (3) facilities be included in the National Department of Health, In-Kind Grant Funded projects so that the projects can be made “shovel ready” and be considered for BFI Funding from National Treasury.
The estimated cost of these multi-year major Infrastructure Project is R1.9 billion and meets the minimum threshold requirement of R1 billion for BFI.
Currently, no budget has been allocated towards these three (3) major infrastructure projects yet, and the request to the National Department of Health is to assist initially with funding the costs of bringing these projects to “shovel readiness” which includes the development of the Clinical Strategic Brief, Concept, Design Development, and the Design Documentation in terms of National Treasury’s Infrastructure Delivery Management System (IDMS) and Framework for Infrastructure Delivery Procurement Management (FIDPM).

Committee Recommendations

The Committee recommends the following to the MEC for Health in the Eastern Cape:

Human Resources

Ensure that the staff complement in all health facilities is improved, by ensuring that clinical and non-clinical positions are filled.
Review organisational structures of health facilities to ensure alignment of programmes with budget structures.
Increase funding for academic training to increase the pool of specialists.
Support services staff working conditions should be improved upon.
The moratorium on the appointment of non-clinical staff needs to be reconsidered, given the impact on clinical services.
The provincial department should prioritise the employment of skilled people from the Nelson Mandela Bay Metro for employment opportunities in that region, regardless of race and gender
The Acting CEO of Livingstone and Port Elizabeth Provincial Hospitals who is being accommodated at the expense of the Department must be reconsidered.

Financial Management

Provincial Department should report to the Committee on progress made in the implementation of the Integrated Medico-Legal Strategy.
The Provincial Department should ensure that all health facilities have proper filing systems to mitigate the theft of patient’s records.
Present to the Committee its plans to address and eliminate accruals.

Infrastructure

Urgently address infrastructure challenges in all the facilities visited. Present the Committee with a quarterly report on the implementation of the Infrastructure Projects.
Prioritise an urgent intervention with regard to inadequate and dilapidated infrastructure at Port Elizabeth Provincial Hospital and Dora Nginza Regional Hospital.
Generators should be tested and maintained on a regular basis.
Integrate all health infrastructure maintenance plans and ensure that budgets are appropriately ring-fenced and spending levels are maintained.
The Provincial Department should continue to liaise with the National Department of Health to secure extra funding for infrastructure projects.

Medical equipment

Ensure timeous procurement of essential medical equipment.
Ensure that Service Maintenance Agreements (with the service provider) are in place for medical equipment so that medical equipment is maintained timeously.
Maintenance budgets of essential medical equipment should be prioritised.
Calibration of emergency medical equipment should be prioritised on a regular basis.

Essential support services

Ensure that laundry machines are upgraded, inclusive of a maintenance plan.
Ensure that hospitals have in-house laundry services to ensure adequate supply and availability of quality linen.
Ensure adequate laundry staff to improve turnaround time.

Governance and leadership

The decomplexing of Livingstone Hospital and Port Elizabeth Provincial Hospital should be prioritised. The organograms should be finalised and vacant posts filled, for the hospitals to improve service delivery.

Conclusion

Unless otherwise indicated, the Eastern Cape Provincial Department of Health should respond to the Committee recommendations in three months from the day the report is adopted by the House.

Report to be considered.

Documents