4. Report of the Select Committee on Social Services on an Oversight Visit to the OR Tambo District Municipality in the Eastern Cape, Dated 18 November 2014

PARLIAMENTARY DELEGATION

1. Ms LC Dlamini – Chairperson: Select Committee on Social Services 2. Ms LL Zwane 3. Mr HB Groenewald4. Mr M Khawula 5. Ms TK Mampuru – Committee Whip6. Ms PC Mququ7. Ms TG Mpambo-Sibhukwana8. Mr DM Stock 9. Ms MF Tlake10. Ms L Matthys - Apology

PARLIAMENTARY OFFICIALS

1. Ms Thabile Ketye – Content Advisor2. Mr Gunther Mankay – Committee Assistant 3. Mr Mkhululi Molo – Committee Researcher4. Mr Sean Whiting – Committee Researcher

1. INTRODUCTION

The Select Committee on Social Services conducted an oversight visit to OR Tambo

District Municipality, in the Eastern Cape during the week of 21-14 October 2014.

This followed a decision taken during the National Council of Province’s (NCOP)

Annual Planning session held on 1-2 September 2014.

OR Tambo District Municipality is one of eight district municipalities in the Eastern

Cape. It is the biggest district1 in the province and comprises of King Sabatha

Dalindyebo, Mhlontlo, Nyandeni, Port St John’s and Ngquza Hill Local Municipality.

The district has 168 health care facilities (please refer to Table 1). Within the district

some health care facilities serve between 20 000 and 30 000 people while the World

Health Organisation (WHO) norm is 1:10 000 people.2 However, there are health care

facilities that serve far less than the WHO norm.

1 The total population is estimated to be at 1 364 941. Census 2011. Statistics South Africa. 2 World Health Statistics: Indicator Compendium. 2012. World Health Organization.

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Table 1: Composition and number of heath care facilities in OR Tambo District

Municipality3

SUB-DISTRICTS

HEALTH CARE FACILITIESTertiary Hospital

Regional Hospital

District Hospital

Community Health Centres Clinics Mobiles

King Sabatha

1 1 1 5 44 2

Mhlontlo - - 3 2 25 2Nyandeni - - 4 3 46 5Qaukeni - 1 1 - 20 2Total 1 2 9 10 135 11

2. PURPOSE OF THE OVERSIGHT

The purpose of conducting oversight at OR Tambo District Municipality was to assess

the progress made in the implementation of the National Health Insurance (NHI), in

one of the eleven pilot districts in the country. The District, which is the only NHI

pilot district in the Eastern Cape, has been one of the worst performing health districts

in the country. In the South African Health Barometer it was ranked the worst district

(in the country) in the most important indicators.4 A study conducted by the Health

Systems Trust found that OR Tambo has the worst rate of newborn deaths – 20.8 of

babies per 1000 births died in the district compared to the 10.2 national average. OR

Tambo district has been reported to have the highest number of child deaths due to

diarrhoea (224 deaths) in the country5 and the third highest deaths of children under a

year. In addition, almost triple the number of children under-five died in the district’s

facilities in comparison to the national average (11.4%). In a recent survey it was

reported that OR Tambo district also had the second highest teen pregnancy rate in the

country (measured by how many births are to women under 18).Error: Reference

source not found

This report provides an overview of the areas the oversight focused on, highlights the

findings from the sites that were visited, and challenges experienced at the health care

facilities. Based on these, recommendations and issues for follow-up were identified

and made.

3 Information received from the Department of Health Eastern Cape. 4 District Health Barometer 2011/12. Health Systems Trust. 5 District Health Barometer 2013/14. Health Systems Trust. .

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3. FOCUS AREAS OF THE OVERSIGHT

The NHI is a form of mandatory insurance that supports a system of universal health

care coverage where every citizen (and legal long-term residents) in South Africa is

covered.6 This innovation is aimed at addressing past and present imbalances on

access of health care services in the country. The core strategy behind this health care

system is ensuring an efficient, effective and quality driven health service delivery

through the Primary Health Care (PHC) approach - thus a strong focus on health

promotion and prevention services at the community and household level.

The objectives of the NHI are:7

To improve access to quality health services for all South Africans,

irrespective of whether they are employed or not;

To pool risks and funds so that equity and social solidarity will be achieved

through the creation of a single fund;

To procure services on behalf of the entire population and efficiently mobilise

and control key financial resources; and

To strengthen the under-resourced and trained public sector so as to improve

health systems performance.

Broadly, the following NHI Grant outcomes8 informed the site visits:

Strengthening district health system,

Improved access to quality of health services,

Strengthened efficiencies of the public health sector and improved health

system performance, and

Improved management of health systems and services at a district level,

In terms of assessing progress in the implementation of the NHI in the pilot district,

the Select Committee focused on the following imperatives for NHI:

a) Infrastructure Development and Management

Accessibility of health care facilities6 National Health Insurance in South Africa, Policy (Green) Paper. 2011. Department of Health.7 Matsoso P. National Health Insurance: The first 18 months. South African Medical Journal, 2013, 103 (3): 156-158. National Health Insurance: The first 18 months.8 Health-e. 2013. Retrieved from: http://www.health-e.org.za/2013/11/25/national-health-insurance-pilot-district-business-plans/.

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Physical infrastructure of the health care facilities (building, waiting

room/reception, etc.).

Availability of health care resources, for example, an ambulance; beds in a

hospital.

What infrastructure programmes are being implemented? If there are any,

what is the status of those? When were they started? When are they meant to

be finalised?

b) Human Resource Planning, Development and Management

What is the staff complement – family physicians, nurses, specialists, etc?

What training has the staff/capacity building programme have the staff

received/attended? When did it take place?

Staff complement by category and gender

What is the nurse-patient ratio?

Are performance agreements in place?

Administration issues including a good filing system and filling of vacancies.

c) Quality of Health Services

Cleanliness of health care facilities,

Safety and security of staff and patients,

Attitude of staff towards patients,

Infection control,

Long queues,

Drug stock-outs/Availability of medicines.

d) Re-engineering of the Primary Health Care System (PHC) within three streams

(i.e. Schools Health Programme, Municipal Ward-Based Primary Healthcare

Agents, and District Specialist Health Teams)

Do these programmes and/or teams exist in the district? What services do they

provide? How often do the school-based/ward-based outreach/district health

teams visit schools/communities?

e) Contracting of General Practitioners (GPs) and other Health Professionals, to

work in public facilities

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Does the district have any partnerships with the private sector? What is the

nature of these?

f) Strengthening hospital performance

What are the mechanisms of improving provision of health care services in the

facility (hospital/clinic)?

4. SITES VISITED DURING THE OVERSIGHT

Oversight of this NHI pilot district entailed meeting with relevant role-players and

stakeholders (within the OR Tambo District and the Province), as well as undertaking

site visits at five health care facilities, viz.:

Mthatha General Hospital,

Nelson Mandela Academic Hospital,

St Barnabas Hospital,

Nessie Knight Hospital, and

Bambisana Hospital.

The mode of information sharing was largely through power-point presentations led

by hospital Chief Executive Officers (CEOs). These were followed by discussions

where the Members of Parliament (MPs) asked questions to explore and probe on

issues raised in the presentations. In addition to those engagements, the delegation

walked around the health care facilities. Information presented in this report therefore

comes from the information collected from presentations and observations.

4.1 Mthatha General Hospital and Nelson Mandela Academic Hospital (Mthatha)

4.1.1 Findings

Nelson Mandela Academic Hospital (NMAH) is a teaching hospital within the

Mthatha hospital complex. The NMAH has good infrastructure and the complex is

easily accessible to the community. However the Mthatha “Regional” Hospital has

old dilapidated buildings which require reconstruction.

Mthatha General Hospital is being developed into a regional hospital. The hospital

complex will include Bedford Orthopaedic Hospital, which will be converted into a

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ward for NMAH. NMAH is being developed into a general hospital. In future, these

two hospitals will have (two) separate budgets. A CEO has recently been appointed

for the Mthatha “Regional” Hospital. However, the development of organograms (for

the two health care facilities) is still underway. The process of re-developing the

health care facility/complex started in August but still use the same structures which

are located in Mthatha “Regional” Hospital.

Within the complex, there is a one-stop centre for ex-miners. The health care facility

also offers an eye camp to decrease cataract cases, and NMAH has a Specialist

Department with new accreditations.

The health care facility uses a manual filing system.

4.1.2 Challenges

It was reported that poor/negative attitude of clinical staff remains a challenge. At

times it is deliberate, but at times it is due to stressful working conditions.

There is a high volume of trauma patients which leads to long waiting times.

However, the health care facility is expecting private orthopaedic surgeons to be

contracted. In addition, on a seasonal basis the health care facility experiences a high

volume of complicated circumcision cases.

There are budgetary constraints which results in some critical posts not being filled.

The health care facility has a shortage of Pharmacists (among others). According to

the NMAH CEO, currently there is no budget for NHI readiness although OR Tambo

is a pilot district.

The clinical infrastructure and equipment is inadequate, particularly taking into

account the rationalizing of the complex. The NMAH has 588 beds but require 800 in

total. There is no proper oncology unit thus only chemotherapy is offered and patients

are transferred to East London. The hospital also required a nephrology and renal unit.

There is no tuberculosis (TB) hospital in the area which means that those patients

must be transferred as per the need. Children’s beds are insufficient, and there is a

shortage of offices and lecture rooms. It was also reported that Mthatha “Regional”

Hospital experiences water challenges.

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Patients travel long distances to reach the health care facility, and there is no in-house

accommodation for them. In the interim there is an attempt to acquire a park home for

mothers who are waiting for their children who have been admitted. To minimise long

waiting times, the health care facility is open every day including on weekends and

public holidays.

4.1.3 Recommendations and Issues for follow-up

Filling of critical posts should be prioritised. There should be a strengthened outreach

programme in the community with a focus on primary health care and provision of

quality care. This would also minimise long waiting times in the Out Patient

Department.

The provincial department should look into fast-tracking the rationalization process

and development of organograms. This should be done in line with budget allocations.

4.2 St Barnabas Hospital (Libode)

4.2.1 Findings

This is an old hospital which was started in 1893 by Missionaries. This facility had a

mental health clinic which was closed in April 2013.

The hospital has a good security system. Outside the hospital there are (water)

reservoirs which require fencing.

The CEO indicated that the logistical information system (LOGIS) was installed at the

hospital to fast-track procurement services.

There is a challenge in the reading and use of the allocated budget. According to the

report provided by the CEO, over 80% (R86 644 334.00) of the total budget

(R100 401 971.00) has been allocated for compensation of employees; and the

remainder (R12 898 975.00) on goods and services. In addition, an overall 64% has

already been spent.9

9 The figures provided do not add up.

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4.2.2 Challenges

The hospital is not easily accessible, and there is a need for transport facilities. In

addition, the hospital is experiencing a high vacancy rate exacerbated by the myth of

non-payment of pension funds. According to the CEO, some professional nurses leave

the health care facility to become Ward-Based Team Leaders. Generally there is a

poor response to adverts, especially of clinical staff – people do not see an incentive

to work in the area.

Building and improvement of the physical infrastructure is required, especially for the

TB patients. Staff accommodation remains a challenge. Doctors are accommodated in

four modular structures. Mental health patients are nursed in a general ward – they are

observed over 72 hours and then referred to the nearest mental health care facility.

The Out-Patient Department (OPD) is congested and requires an extension. There is

no maternity waiting home which is a requirement in terms of Campaign for

Accelerated Reduction of Maternal Mortality in Africa (CARMMA). There are no

isolation wards to control/manage infection. There are no dryer machines in the

laundry room, thus linen is hung outside to dry. In terms of staff, accommodation is

required. However, the CEO indicated that accommodation and a resource centre will

be built by the Walter Sisulu University Foundation, and construction will start in

early November 2014.

Currently, there is no space for the safe-keeping of patient records which may lead to

misfiling and loss of records.

The hospital experiences drug stock-outs as the medical depot does not always supply

all the ordered medication. In addition, servicing and procuring of medical equipment

is a challenge.

On a seasonal basis (mainly June and December) the hospital experiences an increase

of septic initiates.

4.2.3 Recommendations and Issues for follow-up

The provincial department should ensure that there is a maternity home in the

hospital, and investigate how the hospital laundry services could be improved. In

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addition, a progress report on these including building and upgrading plans and

implementation thereof should be provided to the Select Committee.

The district should strengthen primary health care (PHC) awareness and outreach in

the communities.

The hospital management should be capacitated and supported in terms of budgeting.

The issue of vacancies should be noted and addressed by the provincial department.

4.3 Nessie Knight Hospital (Sulenkama, Qumbu)

4.3.1 Findings

This is an old mission hospital (built in 1927) which requires redevelopment and

upgrading (as it has never been upgraded since) – the infrastructure is dilapidated. The

nurses are accommodated in caravans behind the hospital. The wards are poorly

ventilated. However, COEGA Development Corporation has been commissioned to

re-build the hospital as part of the national Hospital Revitalisation Programme within

3 years. The construction is on Phase 2 (earthworks)10. Phase 1 has been integrated

with Phase 2. Phase 3 includes building of staff accommodation and Phase 4 includes

building the hospital complex.

In paper, the hospital has 150 usable beds with 177 that are approved. However in

reality only 100 beds are usable. The new hospital will then only have 100 beds.

The hospital is not easily accessible. Lilitha Nursing College, which is located within

the same hospital complex, belongs in a different programme and thus has a separate

organogram and budget. The hospital waiting time is an average of 4 to 5 hours (this

is written on the Reception’s Notice Board). The hospital has a poor filing system.

The CEO indicated that there is a Hospital Board which has been existence for the

past 3 years. He also indicated that in terms of mortuary services, which are available

10 This is inclusive of the repairing of old water pipes and upgrading of electricity.

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24 hours a day, daily; they have a Mortuary Attendant who is relieved by Porters

when the need arises.

4.3.2 Challenges

The current CEO only started at the hospital in April 2014. The hospital has 225

employees and a vacancy rate of 36%. The high turnover started recently (about four

months ago) due to myths about pension pay-outs.

The hospital has an over-expenditure of about 8% on compensation of employees

(COE) due to an accrual of HR benefits from the previous financial year. The CEO

reported that the COE expenditure is at 58%, with about 53% of the overall budget

having spent.

The hospital’s organogram is outdated and does not take into account the current

needs of the institution. The hospital relies on the personnel and salary (Persal) system

in terms of its staff establishment. There is an Acting Clinical Manager and an Acting

Quality Assurance Manager. The post was last filled in 2009. This post is being re-

advertised by the provincial Department. In 2010, the post was advertised but there no

responses. Following that head-hunting took place and a candidate was identified,

however the candidate received an offer at the NMAH. Currently there is no

Radiographer; and the hospital uses a courier service for laboratory services.

Internet connectivity is functional in the hospital however the hospital receives

limited bundles. The Basic Accounting System (BAS) is working well but there is no

LOGIS.

Between the two quarters of 2014, the case fatality rate has increased (from 8.6% to

11%), case fatality rate for surgery separations increased (from 2.4% to 8%) and

perinatal mortality rate increased from 3% to 8.5%. The main causes of the fatality

rates are diarrhoea, pneumonia and malnutrition for the children under 5 years. On a

positive note, cervical cancer screening among women 30 years older took place in

the second quarter.

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There is only one ambulance that is accessible to the hospital, which is only used for

maternity cases. When there are patients who need to be referred to another hospital,

they are transported with a van.

There are no isolation wards/units in the hospital. This creates a challenge when there

are patients suffering from Tuberculosis (TB). This includes Multi-Drug Resistant

(MDR) and Extreme-Drug Resistant (XDR) TB patients which the hospital is not

well-equipped to assist (and does not admit) There is no TB ward, and thus patients

are nursed in a partially open are with no ablution facilities.

4.3.3 Recommendations and Issues for follow-up

The provincial department should provide the Select Committee with quarterly reports

on progress of the hospital construction project; as well as the project plan which

shows the integration of Phases 1 and 2.

The provincial and district departments should fast-track installation of LOGIS at the

hospital, and acquisition of Emergency Medical Services (EMS) for the hospital so

that patients are properly serviced and transported.

Awareness-raising and advocacy should be done in the district so that health staff are

sensitised about the myths of non-payment of pension funds.

The provincial department should find an interim workable solution for the treatment

of TB patients in the hospital.

Filling of critical posts should be prioritised by the provincial department.

4.4 Bambisana Hospital (Lusikisiki)

4.4.1 Findings

There are no visible health facilities in the area (except for this hospital). The physical

infrastructure of the hospital needs upgrading and the staff accommodations needs to

be built as they stay in shacks. There was also an indication of electrical power

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challenges (in the hospital). This is another hospital that has been included in the

national Hospital Revitalisation Programme.

The hospital is experiencing a high nurse vacancy rate at the hospital (more recently)

due to myths about loss of pension funds. In addition, the post of Hospital CEO is

vacant. Dental services and abortion services are not provided at the hospital. Patients

were seen wearing gowns written TB at the back.

There is no proper fencing at the back of the hospital although there are security

guards at the gate.

There was a community picket outside of the hospital gate on the day of the site visit.

Members of the community raised a number of issues which refer to the staff attitude

towards patients, availability of medication and food, infrastructure and facilities, and

emergency medical services.

4.4.2 Challenges

Accessibility to the hospital may be a challenge considering that there are no available

ambulances and employed drivers.

The Acting CEO indicated that internet connectivity is functional in the hospital

however the BAS and Persal systems are not functional due to problems with the data

line. As a result of this, the hospital staff have to travel to another health care facility

to access those systems. This also applies to accessing medication when there are

stock-outs.

The hospital is one of many health care facilities in the province that have an outdated

organisational structure, and thus health care facilities rely on a Persal staff

establishment. According to the Persal data, there are 209 employees in the hospital

with a 10.5% vacancy rate. This includes one Clinical Manager and three additional

doctors, with one being a sessional doctor.

The term of the Hospital Board ended in September, thus there is no Board currently.

However, according to the District Health Systems Manager a process is underway at

a political level to appoint Board Members.

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It was reported that the mortuary is closed over the weekends. This is following an

incident that was found of porters taking bodies of the deceased (from the village) and

keeping them in the mortuary without the knowledge of hospital management.

According to the Acting CEO patients receive a balanced diet but sometimes run out

of stock and then feed patients what is available (usually soup, pap and potatoes). At

times this is due to slow payment of service providers. The Chief Financial Officer

(CFO) from the provincial department explained that in terms of supply chain

management (SCM), payment is made within 30 days in the province. However there

may be delays when there rendering of services happens outside the official order.

The Clinical Manager indicated that nurses provide PHC after hours, and a doctor that

is working after hours only provides support.

4.4.3 Recommendations and Issues for follow-up

The CFO indicated that construction of a new hospital will be taking place in the not

so distant future, and the provincial office will provide the Select Committee with a

project plan in this regard. With the new building, the number of beds would be

reduced due to the rate of bed use – from 134 to 76. In addition, the Select Committee

will be provided with a quarterly update on the building of the new hospital.

The organogram and thus staff functionality need to be reviewed.

Overall, management needs to be strengthened. Management training should be

offered to the hospital managers.

There should be supervision at the mortuary. The hospital management should revisit

the policy of operating hours of the mortuary.

Shift hours for doctors working at the hospital should be considered, or the use of on-

call doctors should be better managed and facilitated.

5. CONCLUSION

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The Select Committee visited five health care facilities at OR Tambo district, during

this oversight. The facilities were visited with various stakeholders and role-players,

including Members of Parliament from the Eastern Cape Provincial Legislature,

provincial and district officials from the Department of Health.

This proved to be a fruitful exercise as it enabled the stakeholders and role-players to

understand the status of health care service provision in the NHI pilot district and also

thoroughly engage on observations made and reported matters.

In the main, the following are crucial in strengthening the OR Tambo district health

system:

Upgrading and/or rebuilding of health care facilities;

Addressing the challenges caused by the rationalization process, including

creation and finalisation of organisational structures for institutions/health care

facilities;

Filling of critical clinical and non-clinical posts;

Installing and/or improving supply chain management systems to better enable

provision of quality health care and services;

Improving emergency medical services;

Provision of support and capacity building to personnel as per required; and

Comprehensive monitoring and reporting progress.

Following this undertaking, the Select Committee on Social Services will (continue

to) undertake oversight on the health care facilities visited on 21-24 October 2014.

Report to be considered

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