PUBLIC SERVICE COMMISSION

REPORT ON A SERVICE DELIVERY

INSPECTION OF HOSPITALS AND CLINICS

REGARDING AVAILABILITY OF MEDICINES

AND MEDICAL EQUIPMENT AND THE ROLE

OF HEALTH DISTRICT OFFICES

DEPARTMENT OF HEALTH:

LIMPOPO PROVINCE

APRIL 2014

Report on Service Delivery Inspection of District Hospitals and Clinics regarding Availability of Medicines and Medical Equipment and the

Role of Health District Offices in the Department of Health: Limpopo Province i

TABLE OF CONTENTS

FOREWORD ................................................................................................................................ iii

LIST OF ACRONYMS ................................................................................................................. iv

1. INTRODUCTION ................................................................................................................. 1

2. OBJECTIVES OF THE INSPECTIONS ...................................................................................... 2

3. SCOPE AND METHODOLOGY .............................................................................................. 3

3.1 Scope .......................................................................................................................................... 3

3.2 Methodology .............................................................................................................................. 3

4. LIMITATIONS OF THE STUDY .............................................................................................. 4

5. KEY FINDINGS ON ANNOUNCED INSPECTIONS ................................................................... 4

5.1 Contextual background .............................................................................................................. 4

5.2 Management of Medicines ........................................................................................................ 6

5.2.1 Product selection ....................................................................................................................... 6

5.2.2 Procurement .............................................................................................................................. 7

5.2.3 Distribution and storage ............................................................................................................ 8

5.2.4 Rational use, monitoring and evaluation ................................................................................. 13

5.2.5 Management Support .............................................................................................................. 17

5.3 Management of medical equipment ....................................................................................... 18

5.4 Governance of health facilities ................................................................................................ 23

5.5 Challenges ................................................................................................................................ 24

6. KEY FINDINGS ON UNANNOUNCED INSPECTIONS ............................................................. 24

6.1 Observing facilities ................................................................................................................... 24

6.2 Observing access to information ............................................................................................. 33

6.3 Observing Staff ......................................................................................................................... 34

6.4 Talking to Citizens .................................................................................................................... 34

6.5 General Observations .............................................................................................................. 36

7. IMPLEMENTATION OF THE PSC RECOMMENDATIONS ....................................................... 36

8. READINESS OF THE INSPECTED FACILITIES FOR THE ROLL OUT OF THE NATIONAL HEALTH

INSURANCE (NHI) ............................................................................................................. 36

9. RECOMMENDATIONS ....................................................................................................... 37

9.1 Announced inspections ............................................................................................................ 37

9.2 Unannounced Inspections ....................................................................................................... 38

10. CONCLUSION .................................................................................................................... 39

Report on Service Delivery Inspection of District Hospitals and Clinics regarding Availability of Medicines and Medical Equipment and the

Role of Health District Offices in the Department of Health: Limpopo Province ii

11. ACKNOWLEDGEMENT ....................................................................................................... 39

TABLES

Table 1: Objectives of inspections .................................................................................................... 2

Table 2: Sites and dates of inspections ........................................................................................... 3

Table 3: Prevalent diseases in the facilities visited ........................................................................ 7

FIGURES

Figure 1: Medicine management cycle ............................................................................................ 6

Figure 2: The end-to-end process of ordering medical supplies from the MSD ........................ 8

Figure 3: The end-to-end supply chain of pharmaceuticals ......................................................... 9

Figure 4: Medicine about to be dispatched to clinics from the buffer stock of the Ellisras

hospital pharmacy ............................................................................................................ 10

Figure 5: Painted windows at Namakgale Clinic .......................................................................... 12

Figure 6: Pharmacy windows closed with cardboards at Bela-Bela Clinic ............................... 12

Figure 7: Cluttered storeroom at Messina Hospital ..................................................................... 13

Figure 8: Boxes placed on the floor in the storeroom at Ellisras Hospital ................................ 13

Figure 9: Empty shelves observed in the pharmacy at Namakgale Clinic (Zone A) .............. 16

Figure 10: Refrigerator with limited available stock at Namakgale Clinic ................................. 16

Figure 11: X-Ray equipment at Ellisras Hospital is no longer functioning and needs to be

replaced .......................................................................................................................... 19

Figure 12: Surgical lights at Ellisras Hospital no longer function and should be replaced .... 21

Figure 13: Signage of the Ellisras Hospital ................................................................................... 25

Figure 14: Handwritten signage of the Helene Franz Gateway Clinic ...................................... 25

Figure 15: Inside signage at Ellisras Hospital directing patients to specific service points ... 26

Figure 16: Linen items and cleaning equipment at Bela-Bela Clinic presenting an

unattractive look ............................................................................................................. 27

Figure 17: Bed linen used as partitions in consulting rooms at Helene Franz Gateway Clinic

.......................................................................................................................................... 27

Figure 18: Window of the prefabricated structure of the Bela-Bela Clinic covered with

cardboard paper ............................................................................................................ 28

Figure 19: The unused building of Bela-Bela Clinic since it is dilapidated and in a state of

disrepair .......................................................................................................................... 29

Figure 20: Messina Hospital’s dilapidated physical structure .................................................... 29

Figure 21: The damaged ceiling in the kitchen and corridor of Ellisras Hospital .................... 30

Figure 22: A well-groomed garden at Marishane Clinic ............................................................. 30

Figure 23: Mother and sleeping on the floor at Messina Hospital due shortage of beds ...... 31

Figure 24: The untidy records management system at Ellisras Hospital ................................. 32

Figure 25: The fire extinguishing equipment’s service date has passed without it being

serviced ........................................................................................................................... 32

Figure 26: A poster of Batho Pele principles made available in Sepedi at Marishane Clinic 33

Figure 27: A suggestion box at Bela-Bela Clinic .......................................................................... 34

Report on Service Delivery Inspection of District Hospitals and Clinics regarding Availability of Medicines and Medical Equipment and the

Role of Health District Offices in the Department of Health: Limpopo Province iii

FOREWORD

South Africa’s burden of disease, consisting amongst others of a high rate of HIV/AIDS is

consistent with health challenges affecting many developing countries which are

characterized by high levels of poverty. Thus, health care is one of the key government

priorities as well as an essential service which should be accessible to all the citizens of the

country.

Key to ensuring a long and healthy life for all is having sustainable health care infrastructure

that is responsive to the needs of the citizens. To this end, primary health care facilities have

been established to ensure that citizens receive health services at the local level.

Furthermore, the National Health Insurance (NHI) has been established to ensure equal

access to quality health care for all citizens. Amongst others, it is important that health care

facilities should at all times have sufficient medicines as well as adequate medical

equipment for timeous and quality treatment, if government is to succeed in mitigating the

burden of disease and ensuring a long and healthy life for all citizens. Furthermore, health

facilities should function in a manner that is in line with the Batho Pele principles of service

delivery.

It is against this background that the Public Service Commission (PSC) deemed it necessary

to conduct inspections to determine the availability of medicines and medical equipment.

Furthermore, the inspections sought to determine the implementation of the PSC’s previous

recommendations in this area and readiness of the health care facilities for the imminent roll

out of the NHI. Overall, the findings shows that there were challenges of unavailability of

certain medicines and poor maintenance of medical equipment at most inspected health

facilities. Other issues identified related mainly to insufficient accommodation for doctors

especially at Messina Hospital and infrastructure such as poor condition of buildings. The

observed challenges need to be addressed without delay in order to ensure that the facilities

are ready for the implementation of the NHI.

It is a pleasure to present the Report on Service Delivery Inspection of Hospitals and Clinics

regarding Availability of Medicines and Medical Equipment and the Role of Health District

Offices in Limpopo. We believe that the inspections remain a valuable monitoring

mechanism whose findings could contribute towards service delivery improvement.

The PSC wishes to thank officials of the Limpopo Department of Health (LDoH) for their

cooperation and willingness to share information. We trust that the findings will help the

LDoH in its efforts to improve service delivery for sustainable and quality health care.

Report on Service Delivery Inspection of District Hospitals and Clinics regarding Availability of Medicines and Medical Equipment and the

Role of Health District Offices in the Department of Health: Limpopo Province iv

LIST OF ACRONYMS

ARV Anti-Retroviral

AIDS Acquired Immune Deficiency Syndrome

AO Accounting Officer

CEO Chief Executive Officer

DHP District Health Plan

NDoH National Department of Health

DPC Drug Pharmaceutical Committee

EA Executive Authority

EDL Essential Drugs List

HB Haemoglobinometer

GPP Good Pharmacy Practice

HIV Human Immune Virus

LDoH Limpopo Department of Health

MEC Member of Executive Council

MSD Medical Supplies Depot

NCS National Core Standard

NDPSA National Drug Policy of South Africa

NEMLC National Essential Medicines List committee

NHA National Health Act

NHC National Health Council

NHIS National Health Insurance Scheme

OHS Occupational Health and Safety

OPD Out-Patient Dispensary

PSC Public Service Commission

PTC Pharmaceutical and Therapeutic Committee

SCM Supply Chain Management

SLA Service Level Agreement

SoPs Standard Operating Procedures

STG Standard Treatment Guidelines

ToP Termination of Pregnancy

VCT Voluntary Counseling and Testing

WHO World Health Organisation

1

1. INTRODUCTION

South Africa (SA)’s burden of disease mainly consists of HIV/AIDs (i.e. Human

Immunodeficiency Virus/Acquired Immune Deficiency Syndrome), communicable diseases,

non-communicable diseases, and trauma emanating from violence and injuries with

consequent high levels of morbidity and mortality1. The impact of this burden of disease is a

shortened life expectancy. To address this burden of disease, government at its Cabinet

Lekgotla held from 20 to 22 January 2010 adopted as one of its twelve Outcomes: A long

and healthy life for all South Africans.

Health care is one of the key government priorities as well as an essential service, which

should be accessible to all citizens of the country. The foregoing is predicated on a

sustainable quality health care infrastructure. However, unless sufficient medicines as well

as adequate medical equipment are available at health facilities, government will not

succeed in its key objective of ensuring a long and healthy life for South Africans.

The introduction of the National Drug Policy of South Africa (NDPSA), in line with the World

Health Organization (WHO) guidelines, by the National Department of Health in 1996 aimed

at ensuring equal access to medicines for all South Africans. It is the aim of the NDPSA

through the Essential Drugs Programme, which includes an Essential Drugs List (EDL) and

Standard Treatment Guidelines (STG) to ensure that medicines are available at all health

facilities. It is against this background that the citizens expect health facilities to always have

medicines in sufficient quantities as well as the necessary medical equipment.

Furthermore, our constitutional imperatives dictated that government should devolve certain

responsibilities for health services to the provincial and local government2.As a result, the

District Health System (DHS) was established in terms of section 29(1) of the National

Health Act, 2003 to ensure that communities at local level have access to the quality health

care that they are entitled to3. Accordingly, the Provincial Departments of Health created

District Health Offices to facilitate the delivery of health services by hospitals and clinics at

district level. District Offices are expected to play a critical supportive role of ensuring that

health facilities are adequately resourced at all times for the optimal provision of quality

health care to citizens.

It is against this backdrop that the Public Service Commission (PSC) deemed it necessary to

conduct service delivery inspections on availability of medicines and medical equipment at

selected health facilities, as well as to determine the role of Health District Offices in this

regard. Inspections are meant to entrench a citizen and service-centred culture, and

reinforce accountability across the Public Service. Furthermore, they provide the PSC with a

first-hand opportunity to experience what is happening at service delivery sites, and thus

strengthen the oversight work of the PSC. The inspections at the selected health facilities

also presented an opportunity of determining their readiness for the imminent roll-out of

National Health Insurance (NHI).

1 Republic of South Africa. National Department of Health. Strategic Plan for Nurse Education, Training and Practice

2012/13 – 2016/17. 2. Republic of South Africa. National Department of Health. White Paper for the transformation of the Health

System in South Africa . 1997. 3. Republic of South Africa. National Health Act. 2003.

2

Conducting inspections is in line with the Public Service Commission Act, 1997, Section 9,

which provides that “the Commission may inspect Departments and other organizational

components in the Public Service and has access to such official documents or may obtain

such information from Heads of those Departments or organizational components as may be

necessary for the performance of the functions of the Commission under the Constitution or

the Public Service Act4.”

2. OBJECTIVES OF THE INSPECTIONS

According to the PSC’s protocol on announced and unannounced inspections, the broad aim

of inspections is to assess the quality of services rendered by departments, the state of

facilities and the conditions at service delivery sites, in order to ensure adherence to

stipulated regulations and other government frameworks 5 . Table 1 below provides the

specific objectives of an inspection as defined in the PSC Protocol as well as those

pertaining to this inspection on the availability of medicines and medical equipment.

Table 1: Objectives of inspections

Objectives of an inspection Specific objectives of inspections on the

availability of medicines and medical equipment

To afford a personal opportunity to

experience the level of service delivery

first-hand and to see what kind of service

delivery challenges are facing staff.

To determine the availability/adequacy of medicines

and equipment at clinics and district hospitals.

To engender a sense of urgency and

seriousness among officials regarding

service delivery.

To establish the role of district health offices in

ensuring the availability of adequate medicines and

equipment at clinics and district hospitals.

To introduce objective mechanisms to

identify both weaknesses and strengths

towards improving service delivery.

To establish whether provincial departments of

Health have developed guidelines and procedures to

manage the selection, procurement, distribution and

use of medicines.

To report serious concerns about the

quality of service delivery and compliance

with Batho Pele requirements.

To establish whether provincial departments of

Health have developed guidelines to manage the

procurement, distribution and maintenance of

medical equipment.

To carry out investigations of serious

failures as pointed out by inspections; and

To determine the plans of the provincial departments

of Health to resolve any identified problems

experienced in relation to the procurement,

distribution and use of medicines as well as

maintenance of medical equipment.

To improve service user care relations in

order to promote a user-oriented public

service.

To establish the specific institution’s compliance with

the implementation of the Batho Pele Framework in

relation to medicines and equipment.

To determine the challenges experienced by the

district offices of health in ensuring that medicines

and equipment are available at the health institutions.

4. Republic of South Africa. Public Service Commission. Public Service Commission Act. 1997. 5. Republic of South Africa. Public Service Commission. Protocol on Announced and Unannounced Inspections. 2007.

3

3. SCOPE AND METHODOLOGY

3.1 Scope

The inspections sought to gather first-hand information regarding availability of medicines

and medical equipment at selected hospitals and clinics. The selection of the sampled health

facilities in all five (5) districts in the province was mainly guided by the Provincially Based

Commissioner. It should be mentioned that the Vhembe District has been identified by the

National Department of Health for the pilot of the NHI. A representative sample of both urban

and rural health facilities, which included the sites previously inspected in 2009, was

therefore targeted for inspection to determine the availability of medicines and medical

equipment.

All identified sites were preceded by a brief discussion with the officials of the provincial and

relevant district offices in order to obtain an overview of the situation in respect of the sites

visited. For a detailed list of the officials, refer to ANNEXURE A. The table below shows the

inspected sites.

Table 2: Sites and dates of inspections

Provincial/District Component/Institution Date of

Inspections

Sekhukhune District Marishane Clinic 14/10/2013

Waterberg District Bela-Bela Clinic 15/10/2013

Ellisras District Hospital 15/10/2013

Mopani District Namakgale Clinic (Zone A) 16/10/2013

Vhembe District Messina District Hospital 017/10/2013

Capricorn District Helene Franz Gateway Clinic 18/10/2013

Provincial Office/District Offices Polokwane Provincial Office and five (5) District Offices 30/10/2013

Medical Supply Depot 30/10/2013

3.2 Methodology

The methodology for conducting the inspections followed both the announced and

unannounced inspections as prescribed in the PSC’s protocol for conducting inspections6.

The inspections sought to understand the challenges experienced by the citizens in

accessing quality health care especially regarding the availability of medicines and medical

equipment at the sites visited.

To initiate the inspection process, letters were forwarded to the Executive Authorities (EAs)

and the Accounting Officers (AOs) of the National and Provincial Departments of Health,

informing them about the PSC’s intention to conduct inspections in the selected hospitals

and clinics. Furthermore, the inspection team held engagements with the Provincial

Departments to obtain information on medicines and medical equipment.

6 Republic of South Africa. Public Service Commission. Protocol on Announced and Unannounced Inspections. 2007.

4

4. LIMITATIONS OF THE STUDY

The inspections were conducted at selected district offices and health facilities and as such

the findings relate to views and observations made at the said sites. The following limitations

were identified:

The PSC inspection team comprised members who are not experts in the medical

field and relied on the officials of the department to identify the medicines and

medical equipment at the visited sites. It should, however, be mentioned that the

officials appreciated the importance of honesty in this regard as the availability of

these resources will enable them to function optimally.

The inspections did not evaluate the implementation of NHI. However, critical issues

to NHI such as the availability of medicines and medical equipment were inspected to

determine its readiness for roll-out.

5. KEY FINDINGS ON ANNOUNCED INSPECTIONS

5.1 Contextual background

In order to have an accurate context within which the distribution process of medicines and

medical equipment in the Limpopo Province is undertaken, the inspection team held a

meeting with officials of the Limpopo Department of Health (LDoH) and representatives of

the District Offices administering the visited hospitals and clinics on 30 October 2013.

According to the officials the procurement of all medicines as well as medical supplies is

done through the Medical Supply Depot (MSD). However, it was also learnt that the decision

to place the LDoH under administration in terms of Section 100 of the Constitution of South

Africa7 from 2011 until 2013 had a negative impact on the operations of the Department. In

particular, it was indicated that the LDoH was prohibited from taking decisions in relation to

procurement.

Furthermore, the administration came during the period when the LDoH’s contract with

medical suppliers to the MSD had expired. Consequently, the MSD had to purchase

medicine supplies through the sourcing of quotations. Paragraph 3.3 of the National

Treasury Practice No 8 of 2007/2008 sets the threshold of procuring goods and services

using a quotation system to R500 000,00 8 which was acutely insufficient to cater for

approximately 42 hospitals and more than 50 clinics in the province. According to the

officials the situation resulted in delays in sourcing medical supplies due to the intricate

nature of the quotation system which contributed towards shortages of medicines and other

critical medical items throughout the province. To mitigate the challenge, the LDoH

approached the Gauteng Department of Health (GDoH) for a partnership in order to

purchase medical supplies in bulk rather than using the inherently limiting quotation system.

The inspection team was informed that the partnership was of immense benefit to the

province in that availability of medicines at health facilities improved substantially. It was also

indicated that the relationship was still in place at the time of the inspection. The inspection

7 Republic of South Africa. Constitution of the Republic of South Africa, 1996. 8 Republic of South Africa. National Treasury. National Treasury Practice No. 8 of 2007/2008.

5

team is of the view that the collaboration between the departments is in line with the Treasury

Regulation 16A6.6 which states that “The accounting officer or accounting authority may, on behalf

of the department, constitutional institution or public entity, participate in any contract arranged by

means of a competitive bidding process by any other organ of state, subject to the written approval

of such organ of state and relevant contractors”9. Furthermore, it is consistent with the spirit of

co-operative government and intergovernmental relations framework enshrined in Chapter 3

of the Constitution, Section 41(1)(h)(i)(ii), which provides that all spheres of government and

all organs of state within each sphere must co-operate with one another in mutual trust and

good faith by fostering relations and assisting and supporting one another10. The LDoH

should therefore be commended for taking this initiative in the interest of quality healthcare

in the province.

The inspection team also established that there were instances where the hospital

pharmacists ordered certain medicines directly from the suppliers. The inspection team

established that the purchasing of these essential items directly from the suppliers applied to

all hospitals in the province, and ameliorated shortage of medicines to ensure sustained

quality healthcare. This approach is in keeping with the NDoH’s directive based on the

strategies developed and adopted by the National Health Council (NHC) at its meeting held

on 29 to 30 July 2013, to, amongst others, improve hospital performance and ensure

affordability of healthcare11. The strategies were aimed to address “the constant stock-out of

essential medicines as well as the non-availability of critical items of equipment” at health

facilities. Further details of the arrangement are provided in 5.2.2.

Section 33(1) of the National Health Act, 2003 (NHA) requires District Offices to develop

District (DHPs) which outlines, amongst others, the health situational analysis and the

procurement of required medicines. The inspection team was informed that all districts have

DHPs and that it is the responsibility of each District Executive Manager to develop the plan.

The District Executive Managers further indicated that Chief Executive Officers (CEOs) of

hospitals contribute to the development of the DHP by presenting their own needs from

which the District Executive Manager compiles the DHP. The plans for the districts are then

consolidated into the district health services element of a provincial three year plan. Out of

the five (5) District Offices (refer to Table 2 above), only Waterberg provided the inspection

team with a copy of its DHP and therefore, complied with the provisions of the NHA.

Capricorn, Mopani, Sekhukhune and Vhembe did not provide the inspection team with their

DHPs.

According to the Handbook for Clinic and Community Health Centre (CHC) Managers 12,

supervisors should visit these facilities monthly to ensure effective and efficient service

delivery. The District Managers informed the inspection team that they provide support to

health care facilities falling within their control. For instance, they informed the inspection

team that District Pharmacists in the respective Districts play a crucial role in consolidating

9 Republic of South Africa. National Treasury. Treasury Regulations 1999 10 Republic of South Africa. Constitution of the Republic of South Africa, 1996. 11 Republic of South Africa. Department of Health. Strategies to Improve Hospital Performance in South Africa

to ensure Universal Health Coverage, Quality of Care, Hospital Effectiveness and Affordability of Health Care.

12 Republic of South Africa. Department of Health. Handbook for Clinic/Community Health Centres Managers. October

1999.

6

orders for districts, with the support of the hospital pharmacists, and ensuring that the

ordered stock is delivered to the respective health facilities. The inspection team found the

role of the District Pharmacists to be evidence of the support the Districts provide to health

facilities in ensuring sustainable quality healthcare to the public and was in line with the

Handbook. It was also learnt that the MSD has developed a schedule for the whole province

which serves to guide all the health facilities on when to place orders and when to expect the

ordered stock to be delivered.

5.2 Management of Medicines

An analysis of the National Drug Policy of South Africa (NDPSA) indicates that the

management of medicines essentially involves five key functions namely, selection,

procurement, management support, distribution, and use. The diagram below maps the

critical steps of effective and efficient medicine management. As such the findings of the

inspections are structured according to the above-mentioned management process. (It

should be noted that for the purpose of this report, by medicines, reference is also made to

all pharmaceuticals, surgical and medical supplies). In this regard, the findings on the

management of medicines are structured according to this integrated process.

Figure 1: Medicine management cycle

5.2.1 Product selection

Scrutiny of the NDPSA indicates that the National Essential Medicines List Committee

(NEMLC) or National Essential Drugs List Committee (NEDLC), appointed by the Minister of

Health, is responsible for the selection and revision of a national list of essential medicines

for three levels of care, i.e. PHC, secondary and tertiary hospitals. The NEMLC/NEDLC is

composed of experts in all spheres of medical and pharmaceutical practice. During

interaction with officials of the LDoH it emerged that it remains the national responsibility to

Product

selection

Rational use,

monitoring and

evaluation

Distribution

and storage

Procurement

Management support:

Information system

Organisation/staffing

Budgeting

Training

7

determine which medicines are regarded as essential, and whether to be included in the

Essential Drug List (EDL).

Furthermore, in terms of Standard Treatment Guidelines (STG), essential medicines are

selected with due regard to disease prevalence, evidence on efficacy and safety, and

comparative cost. In all the facilities visited, the inspection team was informed that the

availability of essential drugs was guided by the EDL and the prevalence of diseases in the

communities they serviced. Table 2 below depicts the prevalent diseases treated at the

facilities visited.

Table 3: Prevalent diseases in the facilities visited

PREVALENT DISEASES

Name of facility Women’s health Childhood illnesses

Marishane Clinic Hypertension

Diabetes

Tuberculosis (TB)

Common colds

Bela-Bela Clinic TB HIV

Ellisras Hospital Termination of pregnancy (ToP) N/A

Namakgale Clinic (zone A) Sexually Transmitted Infections (STIs)

Hypertension

Diabetes

Asthma (mines and mosquito repellents

are also said to be among the contributing

factors)

HIV

Asthma (mines and mosquito

repellents are also said to be

among the contributing factors)

Respiratory problems

HIV

Diarrhea

Messina Hospital TB

HIV

ToP

Malnutrition, mostly those

coming from across the border

Infant mortality, especially

those below the age of 1 year

HIV

Helene Franz Gateway Clinic STIs

TB

Hypertension

Mental

Teen pregnancy

Cough

Diarrhea

The above table shows that hypertension, HIV and TB are the most prevalent diseases

afflicting women and children at the facilities visited, followed by pregnancy related cases.

The National Development Plan (NDP) 203013 in its definition of the quadruple burden of

disease afflicting SA has recognized the high prevalence of these diseases and has as such,

set out goals aimed at addressing these which include improving services at health facilities

to ensure a sustained quality healthcare. An analysis of the EDL in all the visited health

facilities indicated that the EDL in use consisted of the selected medicines catering for the

above-stated diseases and was, therefore, in keeping with the NDP. The PSC is therefore of

the view that product selection is well institutionalized and contributes effectively toward the

availability of medicines at health care facilities.

5.2.2 Procurement

According to all the facilities visited the process of procuring medical supplies follows the

same procedures whereby:

13 Republic of South Africa. National Planning Commission. National Development Plan 2030.

8

the clinics place orders through the District hospitals,

the District hospitals submit the consolidated orders, including theirs, to the MSD for

processing, and

the MSD delivers such orders directly to the clinics.

The figure below describes the end-to-end ordering of medicine supplies from the MSD as it

is currently applied.

Figure 2: The end-to-end process of ordering medical supplies from the MSD

During interaction with staff, the inspection team established that the hospital pharmacists

play a crucial role of a link between the health facilities and the MSD in ensuring that the

facilities do not run out of medical supplies. Staff members at all the health facilities visited

indicated that they liaise directly with the hospital pharmacists and the latter deal with the

MSD when placing their orders. For instance, at Marishane Clinic orders were sent to St

Rita’s District Hospital, and then the hospital pharmacist sends the orders to the MSD on

behalf of the clinic. The MSD will then deliver the ordered stock directly to the clinic.

As indicated in paragraph 5.1, it was confirmed that there were instances where the hospital

pharmacists will order directly from the suppliers, especially with regard to anti-retroviral

drugs (ARVs) and vacoliters (used for fluids replacement administered via a drip). It should

be mentioned that unavailability of ARVs can result in affected patients defaulting on the

treatment, which may lead to drug resistance with concomitant fatal health consequences.

Vacoliters are crucial in patients who have lost a lot of fluids such as in the case of diarrhea

or bleeding profusely which can lead to loss of life. It is, therefore, the view of the PSC that

the LDoH should be commended for putting these measures in place to ensure a constant

supply of these much needed medical items.

5.2.3 Distribution and storage

It is the objective of the NDPSA to ensure prompt, efficient, timely and equitable distribution

of essential drugs and medical supplies to all institutions. To this end, provincial departments

are in terms of the NDPSA required to develop own standard operating procedures (SoPs)

for the distribution arrangements and storage of medical supplies.

Distribution: Following the meeting with the officials of the LDoH, the inspection team

visited the MSD on 30 October 2013. The purpose of the visit was to establish how medical

supplies in the province are sourced and distributed to the health facilities and to conduct an

in loco inspection of the warehouse. In this regard, the inspection team interacted with the

pharmacists of the depot, receiving and dispensary staff, warehouse management and staff,

Clinics compile their orders

Submit to District hospitals

District Hospitals Submit orders, including theirs, to MSD

MSD processes orders

Orders delivered directly to

hosptals/Clinics after a week

Nursing Staff receive the orders and

record these

9

procurement manager, and storeroom manager who provided key information regarding the

end-to-end supply chain of medical supplies. According to the MSD the figure below

describes the end-to-end supply chain of pharmaceuticals in the province.

Figure 3: The end-to-end supply chain of pharmaceuticals

Based on the figure above, the responsibility of the NDoH is to provide broad policies and

guidelines such as the NDPSA and EDL regarding pharmaceuticals to be procured as well

as their distribution to health facilities in providing quality healthcare to the citizenry. The

LDoH is then responsible for establishing structures and developing standard operating

procedures (SoPs) to ensure effective and efficient service delivery at health facilities. It

emerged during inspections that the MSD is operating without the pharmaceutical license

which must be issued by the South African Pharmacy Council (SAPC) in line with section 22

of the Pharmacy Act, 1974 (Act 53 of 1974) as amended. The inspection team noted that the

license was suspended due to the state of the MSD’s building which did not comply with the

requirements as set by the SAPC, as such, was considered not conducive for storage of the

medicines and other medical supplies. It was further noted that the building will not be

renovated since the lease agreement was expiring and that the LDoH was not making plans

of renewing due to the Ministerial pronouncement regarding health facilities procuring

directly from suppliers in future14. It is the view of the PSC that by operating without the

licence the MSD’s operations were in direct contravention of the mandate of the SAPC which

is “to protect, promote and maintain the health, safety and wellbeing of patients and the

public ensuring quality pharmaceutical service for all South Africans”.

The inspection team further observed the operations at the MSD which included the flow of

orders upon receipt from the hospitals and clinics, and also inspected the products and

infrastructure throughout the warehouse to the point where medical supplies were packaged

for delivery. Generally, the distribution of medicines and medical supplies follows the same

procedure throughout the province. The MSD is responsible for the distribution of medicines

and medical supplies in the province, except for instances wherein hospitals buy directly

from suppliers. The depot has an order and delivery schedule for the whole province which

serves to guide all the health facilities on when to place orders and when to expect stock

ordered. According to the MSD, the health facilities order their medicines and medical

supplies manually by completing a particular form. The foregoing ordering system was also

confirmed by the visited district hospitals and clinics.

14 Republic of South Africa. Department of Health. Strategies to Improve Hospital Performance in South Africa

to ensure Universal Health Coverage, Quality of Care, Hospital Effectiveness and Affordability of Health Care.

National Dept of Health

(NDoH)

Limpopo Dept of Health

(LDoH)

Tenders /suppliers

Medical Supply Depot (MSD)

Regional / District Hospital

/Clinic Patients

10

It also emerged during inspections that district hospitals, from time to time, provide clinics

with medical supplies from their own buffer stocks as and when the clinics run out of stock.

This practice is in line with the NDPSA and ensures that patients were not turned back due

to lack of medicines at the clinics.

Figure 4: Medicine about to be dispatched to clinics from the buffer stock of the Ellisras hospital

pharmacy

Storage: The NDPSA advocates for proper storage and safeguarding of drugs and medical

supplies to ensure the maintenance of quality and security from the time of receipt into stock

up to the time of issue to the patient. In addition, the Good Pharmacy Practice in South

Africa, Fourth Edition, 2010 (GPP) sets out the minimum standards for procurement, storage

and distribution of medicines15. The GPP was developed in line with the scope of practice of

the pharmacy profession as prescribed in terms of Section 35A of the Pharmacy Act, 1974

(Act 53 of 1974). The document maintains that a pharmacist must take all reasonable steps

to ensure that working conditions are so arranged as to protect the safety of the public and

people working in the pharmacy.

All the visited hospitals and clinics were found to have storerooms and pharmacies with

locking burglar doors for all medicines and medical supplies as required by the NDPSA and

GPP. The inspection team, however, noted with concern that these were located directly

next to the out-patient dispensary (OPD) which impacted on patient information

confidentiality. For instance, the layout was such that staff in the storerooms can easily

overhear the OPD nursing staff communicating medical instructions to patients while

dispensing medicines. The other concern related to security of medicines since there was no

15 Republic of South Africa. South African Pharmacy Council. Good Pharmacy Practice in South Africa, Fourth

Edition, 2010.

11

dedicated security staff manning the entrances or equipment used to control access as well

as to search anyone leaving the storerooms to detect any theft. It is the view of the PSC that

the security measures were insufficient and provided an opportunity for theft.

For instance, staff at Messina Hospital raised serious concerns of corruption practices

involving some of its medical personnel which contributed to shortages of medicines. It was

mentioned that there were allegations of incidences where some of the hospital medical

personnel were stealing medicines and charging pregnant women from Zimbabwe an

amount of R3000 and sharing the money amongst themselves. It was further alleged that

some nursing personnel were stealing and selling Cycotec. This medicine is used

commonly in reproductive health to induce labour or in medical abortions. However, it was

suspected that the medication could be used illicitly to perform illegal abortions. The

inspection team was informed that investigations were underway to deal with the allegations.

The increased demand for Cycotec is consistent with the prevalent diseases in the area as

stated in Table 2 above. It further highlights the need for LDoH to intensify its campaign on

sexual behaviour which should involve the community in the area if the unrelenting scourge

of HIV/AIDS in the country is to be effectively dealt with.

Analysis of the LDoH’s SoPs indicated that measures have been provided for the control of

access to the pharmacies and safeguarding (i.e. locking facilities to the pharmacy) of

medical supplies. During interaction with staff in the facilities visited, the inspection team

established that staff members were aware of the applicable provisions of the SoPs. The

inspection team further observed how the inventory received from the MSD was kept in

pharmacies to maintain the quality of medicines and their lifespan. All facilities’ pharmacies

were found to be having thermometers to monitor room temperatures and refrigerators for

storing medicines such as vaccines and insulin, although these were regarded as

insufficient. Staff in all clinics raised concerns of limited space for storing vaccines for

measles due to shortage of refrigerators. At Namakgale Clinic it was observed that there

was only one working refrigerator which limited the amount of stock to be ordered such as

vaccines and other medicines which require refrigeration.

Furthermore, the air-conditioning system of Namakgale Clinic was not working. Although its

windows had curtains, these were not sufficient to prevent the penetrating sun rays which

affected the quality of medicines. As an alternative, the staff resorted to painting the window

panes.

12

Figure 5: Painted windows at Namakgale Clinic

At Bela-Bela Clinic, which is a makeshift of prefabricated material, the windows to the

pharmacy did not have blinds or curtains to prevent the sun rays. Although the air

conditioning system was found to be working, the penetrating sun rays resulted in hot

temperatures in the clinic which forced the clinic staff to use cardboards to cover the

windows.

Figure 6: Pharmacy windows closed with cardboards at Bela-Bela Clinic

Further concerns of limited space in storerooms were noted in most facilities visited. For

example, it was observed at Messina and Ellisras hospitals that space was not sufficient to

accommodate the amount of ordered stock delivered which resulted in stock placed on the

floor. The storeroom appeared cluttered and unprofessional as well as posing a serious

health and safety risk.

13

Figure 7: Cluttered storeroom at Messina Hospital

Figure 8: Boxes placed on the floor in the storeroom at Ellisras Hospital

5.2.4 Rational use, monitoring and evaluation

Rational use: The NDPSA recognizes the key educational role of pharmacists in instructing

patients in the correct use of medicines and to provide preventive health services. During

interaction with the staff, the inspection team observed that the staff members were

adequately trained to ensure that patients were sufficiently guided on the correct use of

medicines. However, the staff had concerns regarding the misguided practices involving

stealing and selling of medicines such as Cycotec and ARVs by some of its personnel as

mentioned above. The use of any medication without proper supervision, especially the use

of Cycotec in suspected termination of pregnancies, may have fatal consequences.

Medication such as ARVs often should be taken under strict supervision including accurate

information on any dietary considerations whilst taking the prescribed treatment to ensure its

efficacy. Furthermore, patients on ARVs require strict monitoring so that they do not default

14

on the treatment which may lead to drug resistance and progression to full blown AIDS with

concomitant fatal results.

Monitoring and Evaluation: The Handbook for Clinic and Community Health Centre (CHC)

Managers, states that supervisors should visit these health facilities monthly16. It follows

therefore that District Offices should oversee the operations of these health facilities to

ensure the effective and efficient service delivery. At hospital level the appointed Chief

Executive Officers (CEOs) should ensure adequate resourcing of the hospitals they manage

in line with the National Health Core Standards. The oversight or supervisory role includes

the effective management of availability of medicines at health facilities. The inspection team

was informed at the facilities visited that the districts did not have an effective system to

monitor drug availability. It was also established that at all clinics there was no verification

mechanism to determine whether the stock purchased was equal to the stock dispensed.

For instance, although stock cards were utilised to manage medicine availability, this was

not an effective and accurate system as it was cumbersome and time-consuming. Since the

stock was directly delivered to the clinics, control was often left to the nurse responsible for

receiving and recording the items with the Assistant Pharmacist only checking the

correctness of the received consignment. It was also noted that the assistant pharmacists

only visited the clinics for support on issues relating to immunization but not actual stock

taking. The system was therefore prone to theft and misuse of resources as items may be

taken out of the clinics without being noticed. Reports of theft of Cycotec mentioned at the

Messina Hospital (refer to paragraph 5.2.3) highlight the concern of the inspection team

regarding the need for an effective monitoring and evaluation system at health facilities.

However, the staff at most of the visited facilities indicated that most medicines listed in the

EDL were available.

Other concerns the staff at Messina Hospital brought to the attention of the inspection team

were as follows:

Staff members indicated that there was a shortage of iron supplements, including at

all the clinics under their supervision.

Medication for HIV patients was not always available due to an increase in demand

resulting from patients who have not been properly initiated into the treatment

programme also accessing the drugs. Examples were cited of refugees from

neighboring countries who, due to political instability in their country, came to South

Africa, which affected the services at Messina Hospital in particular.

Emergency supplies were reportedly not available. For instance, the inspection team

was informed that there was no medication to sedate patients with mental health

conditions. As a result, the hospital staff was forced to handcuff patients to their beds

to prevent them from hurting themselves or physically attacking the medical

personnel. It was further mentioned that some patients who were heavily pregnant

and with complications, risked traveling long and bumpy distances from Zimbabwe

due to political instability, and the hospital would be forced to operate on them. It was

16 Republic of South Africa. Department of Health. Handbook for Clinic/Community Health Centres Managers. October

1999.

15

indicated that these instances would lead to the hospital running out of medicines to

sedate them for the operations.

It was also alleged that the hospital often received patients from private physicians,

who would send their patients to the hospital for prescriptions after consultation. The

inspection team learnt that some of these patients were allegedly not prepared to be

treated by black doctors at the hospital, and would rather go to their own private

doctors. However, these patients would only visit the hospital to obtain their

prescription letters so as to access their medicines at no extra cost. Furthermore, the

said patients would not even sit in the queues but would allegedly pay the Nurse-in-

Charge to jump the queue so that they can be served first. Apart from impacting

negatively on the waiting period at the hospital, this practice contributes to the

shortage of medicine in the institution. It is the view of the PSC that the foregoing

practice raises serious concerns of racism which is contrary to the reconciliatory spirit

of our democratic dispensation. In addition, allegations of lack of professional ethics

and corruption leveled against the Nurse-in-Charge are serious and require

immediate attention if the fight against fraud and corruption is to be won.

At Namakgale Clinic (Zone A) the interviewed staff indicated that there was a shortage of

chronic medicines such as covalent, adalat, and effervescent. According to the staff the

clinic was unable to provide the required treatment to affected patients who were mostly

elderly women. The staff also indicated that for approximately three (3) months the clinic has

been unable to conduct tests for diabetes due to unavailability of testing sticks. Furthermore,

the clinic experienced an insufficient supply of ARV drugs to the extent that the staff had to

give patients half dosages instead of the full dosage. This resulted in patients coming back

again sooner for treatment which further led to long queues and thus increasing the waiting

period due to the attention that should be given to such patients prior to dispensing the

medication. It should be noted that Table 2 above indicates that the clinic deals with cases

of hypertension, diabetes and HIV involving women which are life-threatening and as a

result, it is important that the necessary medicines are always available to manage the

conditions.

Findings of the inspection of the clinic’s pharmacy showed that most shelves for certain

medicines were empty which corroborated the concerns of the staff regarding shortage of

stock. Unavailability of medicines especially for treatment of chronic conditions may lead to

patients defaulting on the required treatment regimen with dire health consequences.

16

Figure 9: Empty shelves observed in the pharmacy at Namakgale Clinic (Zone A)

Figure 10: Refrigerator with limited available stock at Namakgale Clinic

During inspections at the Marishane Clinic, officials indicated that there was a shortage of

surgical supplies, Ferrous Sulphate (i.e. treatment for iron deficiency in pregnant mothers),

anti-psychotic (i.e. for treating mental health conditions) as well as Gastrolyte (i.e. treatment

for diarrhea) drugs. The shortage of Ferrous Sulphate was a serious concern in that

pregnant mothers may experience complications which may lead to fatalities if the iron

deficiency is not detected early and properly managed. Although patients were often referred

to nearby hospitals (i.e. St Rita’s and Jane Furse hospitals), these are approximately seven

(7) kilometres from the clinic. As such, patients were forced to use public transport at a cost

17

of R48.00 for a return trip which is unaffordable since the majority of the community in the

area is poor.

At Ellisras Hospital the staff mentioned that there was a shortage of nebulizer masks and

aspirin. Nebulizer masks are used to clear respiratory congestion in affected patients to

enable proper breathing, and shortage thereof may have serious health implications. It was

indicated that the shortage of nebulizer masks contributed to an infant’s death who also had

a low birth weight which was the main contributory factor. The interviewed staff attributed

unavailability of these lifesaving drugs to a certain supplier not having a valid tax clearance

certificate which was required for trading, and thus delaying the procurement process. The

shortage of chronic medicines in the Ellisras Hospital led to the pharmacist becoming

innovative and would take the contact details of the affected patients and then request

supplies from other hospitals.

According to staff at Bela-Bela Clinic there was a shortage of Worm-go for treatment of

intestinal worms in children from the age of 12 months to five (5) years. The clinic also

experienced shortage of blood glucose sticks or strips which made it difficult for regular

monitoring of sugar levels in patients. Regular blood glucose testing is critical for both early

diagnosis of diabetes and effective diabetes self-management. Concerns of shortage of

medicines were corroborated during inspections at the MSD which attributed the shortage to

the expiry of a tender to supply medicines to all health facilities in the province as stated in

paragraph 5.1.

Scrutiny of the DHP of the Waterberg District indicated that the annual target for availability

of essential drugs at all facilities within the district was 95%. However, an analysis of the

quarterly reports found that availability of essential drugs was at 85%, 93% and 90% in the

first, second and third quarters respectively. This indicates that the District was experiencing

a challenge of achieving its target with regard to the availability of essential drugs at most

health facilities. It is the view of the PSC that the findings are consistent with concerns of

shortage of medicines at most health facilities visited. Although Capricorn, Mopani,

Sekhukhune and Vhembe failed to provide the inspection team with their DHPs, observed

challenges of unavailability of medicines at inspected facilities within their districts suggest

that they were also not meeting their targets.

5.2.5 Management Support

On-going support in terms management systems and processes is crucial for the effective

functioning of facilities.

Information Management and Technology System: According to the NDPSA

computerized inventory control systems should be established in all hospital pharmacies and

clinics, and be linked to computerized inventory control systems in the depots. The objective

is to ensure the prompt, efficient, timely and equitable distribution of essential drugs and

medical supplies to all health care institutions17. The ordering of stock from the MSD is done

manually by completing a particular form. According to the MSD its electronic system for

capturing orders was slow and contributed towards delays in finalising the orders. This was

further exacerbated by insufficient personnel for capturing orders. Furthermore, all visited

17 Republic of South Africa. Department of Health. National Drug Policy of South Africa. 1996.

18

health facilities use stock cards to manage medicine availability. Apart from being

cumbersome and time-consuming, this system is not always effective and accurate as it is

prone to errors. It should be mentioned that storerooms or pharmacies keep stock worth

millions of rands and the lack of an effective electronic inventory system may lead to

inaccurate manual inventory logging and is also prone to manipulation. Previous inspections

of the PSC emphasized the need for the LDoH to provide health care facilities with the

requisite information technology (IT) equipment in order to ensure the improved quality of

service delivery18.

Budget: The inspection team was informed that the budget for procuring medicines and

medical supplies was centralized at the provincial level and managed through the Drug

Pharmaceutical Committee. Although no challenge was raised in this regard, it should be

mentioned that the development of the DHPs is aimed at informing the needs of the health

facilities based on a situational analysis conducted on the type of conditions prevailing in the

areas they service as well as budgetary resources required. It was therefore of concern to

the PSC that only Waterberg District provided the inspection team with its DHPs.

Staffing: The inspection team noted that the Ellisras Hospital did not have a technician to

repair broken medical equipment. As a result, the Facility Manager was also utilised to repair

equipment in certain instances, even though not qualified to do so. This was a cause for

serious concern in that any fault arising from such repairs by an unqualified person may

have serious health consequences with accompanying huge legal implications. It was also

noted that the Marishane Clinic had vacant posts of pharmacists’ posts which had not been

filled for some time. As a result, the nursing staff was utilized in dispensing medicines to

patients instead of conducting their normal duties which impacted on service delivery.

Concerns of capacity constraints at health facilities were previously highlighted by the PSC

during its inspections of primary health care delivery sites in 200919. It is the view of the PSC

that unless staff shortages are addressed without delay, the situation will result in employees

being overworked and thus leading to low staff morale which may impact negatively on the

quality of service delivery.

5.3 Management of medical equipment

Availability of sufficient medical equipment at health facilities is integral to providing quality

health care. Generally, medical equipment or instruments help the medical personnel to

diagnose and/or monitor specific medical conditions as well as to sustain the lives of

patients. As a result, the availability of these and good quality is crucial especially in

emergency situations such as when should be put on a life support machine to keep the

patient’s heart beating and to supports his or her weak lungs while awaiting recuperation.

18 Republic of South Africa. Public Service Commission. Consolidated Report on Inspections of Primary Health Care

Delivery Sites: Department of Health. 2010. 19 Republic of South Africa. Public Service Commission. Consolidated Report on Inspections of Primary Health Care

Delivery Sites: Department of Health. 2010.

19

Procurement: Officials of the LDoH informed the inspection team that the procurement of

medical equipment is centralized at the Provincial Head Office and is undertaken in terms of

the Preferential Procurement Policy Framework Act, 2000 (PPPFMA)20. According to the

officials, the purpose of the approach is to ensure proper control and consistency of

procurement processes in line with the PPPFMA. However, all the visited health facilities

raised concern with the aforesaid approach especially since it resulted in delays of procuring

new or replacing broken equipment that can no longer be repaired. For instance, the staff at

Ellisras Hospital informed the inspection team that the hospital’s X-ray machine was no

longer functional and needed to be replaced. It emerged that the Provincial Head Office was

aware of the matter, but had not addressed it. As a result, the staff was in the meantime

relying on two mobile X-rays. Alternatively, the staff would transfer their patients to Witpoort

Hospital which impacted negatively on the turnaround time to providing quality health care to

patients. This also contributed towards increased workload at the Witpoort Hospital which

led to staff being overworked and resulting in low staff morale.

Figure 11: X-Ray equipment at Ellisras Hospital is no longer functioning and needs to be replaced

20 Republic of South Africa. National Treasury. Preferential Procurement Policy Framework Act, 2000 (PPPFMA).

20

Maintenance of equipment: In terms of the section 38(1) of the Public Finance

Management Act, 1999, as amended (PFMA)21, the Accounting Officer is responsible to

ensure the effective management, including safeguarding, and maintenance of public

assets. Accordingly, Treasury Regulation 10.1.1(a) requires the AO to take full responsibility

and ensure that proper systems exist for assets and that preventative mechanisms were in

place to eliminate theft, losses, wastage and misuse of assets 22 . To this end, regular

maintenance of medical equipment is vital to ensure that it is always operational and safe to

use to meet the healthcare needs, such as in lifesaving situations and to also ensure that it

does not cause further harm to patients. Officials of the LDoH informed the inspection team

that equipment care and control begins with the receipt of a newly acquired equipment item

and continues throughout the item's entire life-cycle. In this regard, the department

appointed a maintenance company to deal with the maintenance of all medical equipment at

health facilities. It emerged that the management of maintenance services rests with the

Provincial Head Office through the signed Service Level Agreement (SLA).

Staff at Ellisras Hospital indicated that they did not have technical personnel on the

hospital’s post establishment to perform maintenance of medical equipment. As a result, it

relied on the appointed contractor. However, it became a challenge for the hospital when the

appointed contractor failed to repair reported broken equipment. It emerged that the hospital

had one working medical ventilator to assist trauma patients with breathing problems, which

was insufficient due to high number of trauma cases arising from motor vehicle accident

injuries. According to staff, the hospital was losing on average one patient every weekend

due to insufficient ventilators. In addition, the hospital’s cardiac monitoring unit was not

working and the equipment for detecting fetal heart was not reliable in that it often provided

incorrect readings. The latter often resulted in the hospital performing many caesarean

sections unnecessarily. It was also indicated that the Provincial Head Office was aware of

the problem. It is the view of the PSC that the situation was untenable and requires urgent

attention especially when lives are lost or put at serious risk. Furthermore, this was not in

keeping with government’s priority of ensuring a long and healthy life for all citizens. It is also

the view of the PSC that lack of regular maintenance of medical equipment was not

consistent with the provisions of the PFMA and related regulations.

21 Republic of South Africa. National Treasury. Public Finance Management Act, 1999, as amended (PFMA). 22 Republic of South Africa. National Treasury. Public Finance Management Act, 1999, as amended (PFMA). Treasury

Regulations, 1999.

21

Figure 12: Surgical lights at Ellisras Hospital no longer function and should be replaced

The inspection team also noted that staff at Ellisras and Messina hospitals was not aware of

the content of the SLA signed between the LDoH and the appointed service provider relating

to the maintenance of medical equipment. As a result, the hospitals were unable to enforce

the provisions of the SLA in ensuring quality service on equipment requiring servicing or

repairs. For example, it emerged that some equipment items ended up not working even

after the service provider had serviced or performed repairs on them. The staff also raised

concern that the service provider’s maintenance contract had expired, however no further

communication was received from the Provincial Head Office on alternative measures while

awaiting the approval of the new service provider. This has resulted in extended delays in

repairing broken equipment which has led to the facilities operating with insufficient

equipment and thus impacting negatively on service delivery. Management of both Ellisras

and Messina hospitals showed the inspection team several equipment items used for the

examination of patients in OPD and wards which either required maintenance or

replacement.

At the visited clinics the inspection team was informed that any broken equipment items

were reported to the respective Area Managers and that the Provincial Head Office would

provide maintenance support either through the appointed company or the departmental

maintenance unit. The inspection team examined the attendance register of the Bela-Bela

Clinic and found that the District Office regularly visited the clinic regarding maintenance,

data and asset verification, and to conduct youth friendly service. However, it was observed

the clinic’s refrigerators required maintenance. This led to the clinic ordering a limited supply

of immunization stock as it did not have sufficient space to keep it.

It was also established at Marishane Clinic that the Provincial Office conducted visits for

equipment quality assurance, amongst others. At Helene Franz Gateway Clinic the staff

members indicated that they receive most support from the Helene Franz Hospital. This was

22

mostly so because the clinic is inside the hospital premises. However, the clinics raised

concerns regarding shortage of batteries for the haemoglobinometers. It was established

that the clinics do not have petty cash to buy the required batteries which result in nursing

staff at Namakgale Clinic using their own money to buy the batteries in order to avoid

disruption of service delivery. Although the efforts of the nurses were clearly a selfless act

which deserves to be commended, it is important that the requisition process is improved to

avoid such measures by the nurses. It should also be noted that the PSC has highlighted a

similar concern during its previous inspections of primary health care sites in 2009 23 .

Generally, it emerged in all the facilities visited that while equipment was available, it was not

always in good working condition. Most of the non-functional equipment in the facilities

visited required maintenance, which seemed to be a major problem, with the hospitals being

mostly affected. It is, therefore, the view of the PSC that both the Provincial Head Office and

District Offices were inconsistent regarding support in this area to ensure effective and

efficient service delivery at the visited health facilities.

Disposal of medical equipment: Section 38(1) of the PFMA requires the AO to ensure the

effective management, including safeguarding, and maintenance of public assets. In line

with the PFMA, the applicable asset management framework requires regular inspection of

assets and identification of obsolete for disposal purposes. Almost all visited facilities

indicated that broken equipment items were timely reported for maintenance and disposal

purposes, the challenges of lack of regular maintenance mentioned above, raised questions

of proper systems being in place to identify obsolete items. The PSC was concerned that

some equipment could be identified for disposal before their life cycle due to lack of regular

maintenance. Such a practice was not in keeping with the PFMA and the concept of value

for money.

Systems and guidelines: Overall, in all the inspected facilities the following could not be

established:

availability of a medical equipment management plan which defines the mechanisms

for interaction and oversight of the medical equipment;

availability or utilisation of policies and procedures governing activities from selection

and acquisition to inspection and maintenance of medical equipment;

management of medical device incidents as the primary responsibility of Risk

Management, including monitoring and reporting of incidents in which a medical

device is suspected in or attributed to the death, serious injury, or serious illness of

any individual in order to provide mitigating actions or remedy the situation;

written procedures that address when medical equipment fails except for the

requisition to purchase new equipment;

the organization conducting inspections, tests, and maintenance of life support

equipment; and

the identification of performance improvement indicators, which are based on

priorities identified by the department, users of medical equipment, and the

appropriate committees relevant for Occupational Health and Safety, where

necessary.

23 Republic of South Africa. Public Service Commission. Consolidated Report on Inspections of Primary Health Care

Delivery Sites: Department of Health. 2010.

23

The foregoing points to a haphazard manner in which the management and maintenance of

medical equipment is handled by the LDoH and needs to be streamlined to ensure that the

situation does not lead to the further deterioration of service delivery at the inspected health

facilities.

5.4 Governance of health facilities

Public funds are used to provide public services and as such, it is important that those

charged with the responsibility to provide such services are held to account to ensure,

amongst others, responsiveness and value for money. It is for this reason that section

41(6)(a) of the NHA requires of the relevant MEC to appoint a representative board for each

public health establishment classified as a hospital and to prescribe its functions and

procedures for meetings. In terms of section 42(1) of the NHA, provincial legislation must at

least provide for the establishment of clinics committees.

Hospital boards: In line with the provisions of the NHA, one of the eight core management

standards of the DHS is that the community acts as a shareholder in hospital management

and its representatives should be on the hospital board24. The inspection team was informed

that hospital boards have been established, and were convening regular meetings. Scrutiny

of the Ellisras Hospital’s service delivery report indicates that the hospital had already

attained annual target of six (6) board meetings by the end of the third quarter. Although this

implied that the board was functional and in keeping with the constitutional principle of public

participation, concerns were however raised of the board interfering in administration

matters. The foregoing points to the possibility of lack of clear governance rules which leads

to the board overstepping its mandate.

Clinic Committees: Clinic committees are meant to give expression to the principle of

community participation at a local level. They also serve as a link between communities and

health services and to provide a conduit to articulate community’s health needs and

aspirations to ensure improved quality of health care. All visited facilities indicated clinic

committees were established as required. The staff indicated that the main activities of the

clinic committees related to solving identified problems between the community and the

health facilities (i.e. complaints management and quality of services), health education and

communities volunteering their services in the facilities in order to improve service delivery.

However, it was learned that the Marishane Clinic’s committee was not functional. The

inspection team was informed that a key factor, amongst others, that impacted on the

functioning of the structure was the lack of a stipend to subsidize clinic committee members’

transport costs to attend meetings. Although the clinic informed the inspection team that a

process was underway to ensure that the committee was operational, the current situation

robs the community members of a platform to empower them in contributing towards quality

health service at the clinic, and was also a violation of the constitutional principle of public

participation.

24 Republic of South Africa. A District Hospital Service Package for South Africa. A set of norms and standards. May 2002.

24

5.5 Challenges

The following challenges were identified as impacting negatively on effective and efficient

service delivery at the inspected facilities:

Recruitment: It emerged that there were no sufficient doctors’ quarters at the Ellisras

Hospital. The situation was further exacerbated by lack of affordable properties in the area

which has led to a high turnover of doctors or challenge in recruiting doctors at the hospital.

Infrastructure: The inspection team observed that there was generally a challenge of space

at most of the health facilities visited. For example, there were insufficient maternity wards

and beds at Messina hospital which results in infants and their mothers sleeping on the floor.

Surplus and expired medicine supplies: The inspection team observed that the MSD had

a large quantity of medicines that could not be distributed to health facilities as it had

expired. It was indicated that agreement had been reached with the supplier to take the

stock back and replace it with a new stock at no cost. The foregoing raises concerns of

proper ordering processes by the health facilities especially considering that some of these

facilities experienced shortage of medicines as indicated in paragraph 5.2.4.

6. KEY FINDINGS ON UNANNOUNCED INSPECTIONS

The findings from unannounced inspections are presented below. Batho Pele as a key

strategy for the transformation of Public Service delivery sets out specific principles that

should be adhered to at all times25. It was the purpose of the unannounced inspections to

determine the extent to which the visited health care facilities adhered to these.

6.1 Observing facilities

Signage: It was observed that all the hospitals and clinics visited had outside signage. The

signage was located either at the main gate or at the entrance to the hospital or clinic. The

Helene Franz Gateway Clinic’s signage was handwritten on a white page and perched up

inside the hospital yard as the clinic is housed in Helene Franz hospital’s premises. The

clinic’s signage seemed unprofessional and was not easily visible to the public. At both

Namakgale and Marishane clinics, the signage was easily noticeable from the respective

main roads. The Ellisras and Messina hospitals were also found to have proper outside

signage. However, there was a need to augment the signage of these visited facilities with

direction signs at key strategic points such as road intersections for optimum accessibility.

For instance, due to be being unfamiliar with the area the inspection team had to ask

residents in order to find the facilities’ locations.

25 Republic of South Africa. Department of Public Service and Administration. The Batho Pele White Paper on the

Transformation of Public Service Delivery, 1997.

25

Figure 13: Signage of the Ellisras Hospital

Figure 14: Handwritten signage of the Helene Franz Gateway Clinic

The inspection team further observed that all inspected clinics and hospitals had clear inside

signage which helped to guide citizens to the various service points and consulting rooms.

The inside signage observed at Ellisras Hospital provides appropriate and accurate

information about particular service points and offices for citizens to easily find their way

around the hospital.

26

Figure 15: Inside signage at Ellisras Hospital directing patients to specific service points

Business hours: The inspection team observed that all the clinics had their business hours

inside their premises but these were not easily visible. Bela-Bela Clinic provides services on

a 24 hours basis, while the rest of the clinics provide only daytime services and were closed

on weekends and holidays. For example, Helene Franz Gateway Clinic’s business hours

indicate that the clinic operates between 07h00 and 16h30 on Mondays to Thursdays and

07h00 to 13h00 on Fridays, and it is closed on weekends and holidays.

Cleanliness: An unclean working environment presents an unprofessional outlook which

creates the impression and expectation in customers that the quality of services they will

receive will be of substandard. The inspection team observed that there were linen items

and cleaning equipment hanging or left outside to dry by the fencing of the Bela-Bela Clinic

which presented an unsightly look.

27

Figure 16: Linen items and cleaning equipment at Bela-Bela Clinic presenting an unattractive look

At Helene Franz Gateway Clinic it was observed that there were no partitions or screens for

consulting rooms to ensure patients’ privacy and confidentiality of their treatment. As a

result, bed sheets were used as partitions to prevent prying eyes. While the nurses’ efforts

were a desperate act to allow some resemblance of privacy, it is the view of the PSC that

was inadequate to afford patients their privacy in line with the Bill of Rights. The practice was

not only unsightly but also infringed of the patients’ dignity.

Figure 17: Bed linen used as partitions in consulting rooms at Helene Franz Gateway Clinic

Condition of the buildings: It was observed that the condition of the buildings at both

hospitals and Bela-Bela and Namakgale clinics raised serious concerns of safety. Bela-Bela

28

Clinic was located in a makeshift structure consisting of two freight containers. Despite the

makeshift structure having been adapted to suit clinic conditions, the height of the steps at

the entrance to the clinic were still unsuitable for elderly people, children and people on

crutches or wheelchairs. Furthermore, the steps still did not have rails for support to prevent

possible injury. The makeshift structure also presented challenges of office space, and as a

result, provision could not be made for the waiting area. According to staff, there were also

challenges with the promised construction of the premises elsewhere. Furthermore, the

observed use of cardboard paper on the windows of the Bela-Bela Clinic not only presented

an unsightly view, but also posed a serious safety risk in case of fire and flouted the

Occupational Health and Safety (OHS) regulations.

Figure 18: Window of the prefabricated structure of the Bela-Bela Clinic covered with cardboard paper

Furthermore, the inspection team observed that the unused building at the Bela-Bela Clinic

remained erect despite the PSC’s finding in 2009 that the building was in a state of disrepair

and therefore, needed to be demolished26.

26 Republic of South Africa. Public Service Commission. Consolidated Report on Inspections of Primary Health Care

Delivery Sites: Department of Health. 2010.

29

Figure 19: The unused building of Bela-Bela Clinic since it is dilapidated and in a state of disrepair

At Messina Hospital the staff informed the inspection team that its building was constructed

in 1912 and that it had since not been refurbished. As a result, the physical structure of the

hospital showed signs of dilapidation and possible further deterioration which rendered it to

be in a state of disrepair. It also lacked office space and the roof was leaking especially

during rainy season which further resulted in soiled and paint peeling off the walls.

Figure 20: Messina Hospital’s dilapidated physical structure

The inspections at Ellisras Hospital found its ceiling in the kitchen and corridor damaged

following the storm in the area and the walls were in a very bad state. According to the staff

the building was also very old, and they were uncertain whether it can still be refurbished.

30

Figure 21: The damaged ceiling in the kitchen and corridor of Ellisras Hospital

The Marishane Clinic had a newly built structure, and its premises were found to be modern

with clearly defined office structure. Its grounds were properly maintained and tidy with a

well-groomed garden as was previously found during the 2009 inspections27. The LDoH

should be commended for ensuring that the clinic remained well maintained, and should

further be encouraged to roll out the practice to other health facilities.

Figure 22: A well-groomed garden at Marishane Clinic

Lack of space: The inspection team observed that the Namakgale Clinic had a shortage of

office space and as a result, nurses were forced to use one consulting room as an office at

the same time. In addition, it was found at Messina Hospital that there was a serious

shortage of beds in the maternity wards to the extent that mothers and their infants were

27 Republic of South Africa. Public Service Commission. Consolidated Report on Inspections of Primary Health Care

Delivery Sites: Department of Health. 2010.

31

forced to sleep on the floor. The practice was not only demeaning and infringing on the

patients’ dignity, but also posed a health risk to them given the fragile state of newly born

babies and the condition of their mothers who had just given birth.

Figure 23: Mother and sleeping on the floor at Messina Hospital due shortage of beds

Records management system: The filing system in Ellisras Hospital was in such a manner

that it would be difficult to locate a file for a patient due to the congested and cluttered filing

room. This may compromise the effective treatment of patients should their files with

important history of their condition not be retrieved. The observed clutter was also hazardous

for the staff members in case of fire which was a clear violation of the relevant OHS

regulations and requirements. Particularly worrying was the fact that the fire extinguishing

equipment of the hospital had been due for servicing by August 2013 already and yet this

had not been done at the time of the inspections.

32

Figure 24: The untidy records management

system at Ellisras Hospital

Figure 25: The fire extinguishing equipment’s service date has passed without it being serviced

33

6.2 Observing access to information

Information: The Batho Pele principle of Information determines that information should be

readily provided to the public to empower them in making informed decisions. It was

observed that all the inspected clinics and hospitals had service charters which were visibly

displayed. Some of the information was also made available in languages predominantly

spoken in the area to enhance access in line with Batho Pele.

Figure 26: A poster of Batho Pele principles made available in Sepedi at Marishane Clinic

Furthermore, there were designated information desks to handle citizens’ queries. Although

in the clinics visited there was no personnel designated for such a function, nursing staff

members indicated that the nurses on duty were readily available to assist citizens on their

arrival at the clinics.

Suggestion/complaint boxes: These boxes were found to be available and strategically

placed in all the facilities visited to enable citizens to raise their concerns and also to provide

input on the desired quality of services in line with the Batho Pele principle of Redress. The

inspection team was informed by staff at Marishane Clinic that a Batho Pele Task Team in

the area was responsible for the management of the complaint/suggestion box. In the other

clinics, the inspection team established that established clinic committees comprising

34

community members were responsible to attend to suggestions or complaints from

community members.

Figure 27: A suggestion box at Bela-Bela Clinic

6.3 Observing Staff

It was observed that staff at all the clinics visited had their name tags on. The picture at the

hospital was different; the nursing personnel had their name tags on whilst some, especially

the pharmacists did not have their name tags on, which made it difficult for ordinary citizens

to identify officials who provide services. However, the staff members were friendly and

appeared to be knowledgeable in their responses.

6.4 Talking to Citizens

Availability of medicines and medical equipment: Most citizens at the visited health

facilities were satisfied that they promptly receive their medication after consultation. For

instance, at Marishane Clinic all interviewed citizens indicated that their experiences in this

area have always been satisfactory and thus receiving their medicines promptly. It is the

view of the PSC that this may be due to the fact that patients at the clinic were able to

receive their medicines such as Ferrous Suplhate from St. Ritas and Jane Furse hospitals.

The PSC is therefore concerned about the state of availability of medicines especially

considering that scrutiny of the progress reports on the DHP for Waterberg showed that the

District failed to meet its target of 95% only achieving 85%, 93% and 90% respectively.

Despite major challenges of shortage or lack of maintenance of medical equipment being

raised by staff at Ellisras and Messina hospitals, interviewed citizens at all the inspected

health facilities did not raise any concerns in this regard. This may be attributed either to

their lack of knowledge of these or rather being oblivious of the key role of the equipment

items in their treatment. For example, at Ellisras Hospital citizens were only concerned about

the delays experienced with the X-ray results and not aware that this may be due to the

35

broken X-ray equipment. It is therefore, the view of the PSC that the concerns of the staff at

the visited health facilities need to be urgently addressed to avoid low morale which may

lead to the paralysis of the institutions and consequent poor service delivery. The current

findings are also consistent with the PSC’s findings in 200928 that there were challenges of

shortages of medicines and medical equipment at the health care facilities which warranted

urgent attention to ensure improved service delivery.

Waiting time: Discussions were held with randomly selected citizens at the facilities visited

and revealed that the majority of them were concerned about the waiting period before

receiving any attention at the clinics. At Marishane Clinic interviewed patients raised

concerns that they sometimes waited for two (2) hours before they could receive medical

attention. According to the citizens the LDoH should increase personnel to improve on

waiting time. Patients at Namakgale Clinic indicated that they sometimes wait for more than

three hours to access the health services and they recommend that the department should

provide more personnel to rescue the situation and that the space is not conducive for the

provision of health services. The same concerns were raised at Bela-Bela and Marishane

clinics.

Redress: The interviewed citizens at Bela-Bela Clinic informed the inspection team that they

were aware of the complaint/suggestion box but that they did not know how or when to use

it. At Namakgale Clinic, patients indicated that they doubt the functionality of the suggestion

box because they did not see any changes. They also indicated that they wanted the facility

to operate for 24 hours and to have a maternity ward as this impacted negatively on them.

The foregoing suggests a gap in how information is communicated to citizens especially

since the PSC made a similar finding during the 2009 inspections29. It also points to lack of

timely feedback or action following receipt of any complaint or suggestion lodged which

results in citizens not finding any meaning to the existence of these redress mechanisms.

Access, courtesy and professionalism: The inspection team was informed by some

patients at Ellisras Hospital that although they reside very far away from Ellisras, they

preferred the Ellisras Hospital despite the fact that there were clinics at their areas. They

cited as reasons for visiting the hospital the fact that they will get the necessary service.

Although there were instances of dissatisfaction with the long waiting period at the hospital

patients/citizens were generally satisfied with the quality of services they received and the

treatment by the hospital. This indicates that the staff members at Ellisras Hospital were

courteous, knowledgeable and professional in their tasks, and they should therefore be

commended.

At Helene Franz Gateway Clinic, patients indicated that the presence of the PSC at the clinic

made a huge difference. They indicated that as a result of the PSC’s presence patients were

receiving the necessary attention they deserved. The foregoing reinforces the concern of

citizens on redress above, which further raises concern that professional employees should

be prodded to do their contractual obligations. Although the PSC appreciates the recognition

of its oversight work by the citizens, it is disheartening to note the concerns of the citizens in

28 Republic of South Africa. Consolidated Report on Inspections of Primary Health Care Delivery Sites: Department of

Health. 2010. 29 Republic of South Africa. Consolidated Report on Inspections of Primary Health Care Delivery Sites: Department of

Health. 2010.

36

this democratic dispensation. It, therefore, points to lack of consequences for those

responsible which suggest poor managerial control at the facility.

Some of the interviewed citizens at Marishane Clinic raised concerns about the long

distances that they travelled to access the clinic which averaged 16 kilomentres.

6.5 General Observations

Water and sanitation: A basin was broken at Marishane Clinic. Although it was reported it

was not repaired. Generally, all the facilities did not report any shortages of water or access

to toilet facilities.

Conducive working environment: Air conditioning systems were not adequate in all the

facilities visited, mostly because they need maintenance.

Parking facilities and security: Parking was not adequate at Bela-Bela and Namakgale

clinics and the rest of the facilities did not seem to have a challenge with regard to parking.

Security measures were provided at all the clinics and hospitals in the form of fencing

around the premises as well as security check points at the main gate. However, the fence

at the Namakgale Clinic appeared worn-out and needed to be repaired in some areas.

7. IMPLEMENTATION OF THE PSC RECOMMENDATIONS

The inspection team followed up on the PSC’s previous recommendations emanating from

the inspections of primary health care facilities conducted in 200930. Overall, the findings

have shown that all six (100%) recommendations at the inspected health care facilities were

implemented by the LDoH. The 100% implementation of the PSC’s recommendations by the

LDoH at the inspected health care facilities is commendable and demonstrates the

commitment of the Department in supporting the PSC’s work in its oversight role as

enshrined in the Constitution. Most specifically, it is in keeping with section 196(3) which

stipulates that “no person or organ of state may interfere with the functioning of the

Commission”. Detailed findings on the status of implementation of the recommendations at

the sampled facilities are attached as ANNEXURE D.

8. READINESS OF THE INSPECTED FACILITIES FOR THE ROLL OUT OF THE

NATIONAL HEALTH INSURANCE (NHI)

The NHI is a financing system which aims to ensure that all SA citizens, including non-

citizens who have attained permanent residence, are provided with essential healthcare,

regardless of their economic status. According to the NDoH, during the first five years of the

NHI pilot greater focus will be on strengthening the following key priority areas:

Management of health facilities and health districts;

Quality improvement;

Infrastructure development;

Medical devices including equipment;

30 Republic of South Africa. Consolidated Report on Inspections of Primary Health Care Delivery Sites: Department of

Health. 2010.

37

Human resources planning, development and management; and

Information management and systems support.

Based on the foregoing, it is the view of the PSC that streamlining of the operations of the

health facilities and health districts has been identified as critical for the success of the NHI.

The ancillary aim of the inspections at the selected health facilities was to further provide the

PSC with an indication of the sites’ readiness for the roll out of the NHI. In this regard, the

inspection team observed that the success of the NHI will largely depend on the LDoH

addressing the identified challenge of inconsistency in the maintenance of medical

equipment at most health facilities. It is also critical to create conducive working conditions

by addressing the accommodation challenges of doctors in order ensure the recruitment and

retention of doctors especially at Ellisras Hospital. An incentives programme could be

devised to offset and mitigate the costs of acquiring own property in the area especially

since Ellisras is experiencing infrastructural development with increased job opportunities

arising from the mining and energy.

Furthermore, infrastructural challenges were observed, which could hinder the roll out of the

NHI if not addressed without further delay. For instance, the dilapidated buildings, insufficient

space, and unavailability of an electronic information system that is linked to the MSD’s

ordering electronic system, at most health facilities visited impacted negatively on the quality

of service delivery. However, should these glitches not be promptly managed they have the

potential to replicate themselves throughout the province and thus impact negatively on the

effectiveness of the NHI. Notwithstanding the foregoing challenges, and depending on how

soon the identified challenges are addressed, the PSC is confident that the facilities were

ready for the implementation of the NHI.

9. RECOMMENDATIONS

The recommendations contained in 9.1 and 9.2 below emanate from the inspections. These

recommendations should apply to all health facilities in the province that may be

experiencing similar challenges and not only those that were visited by the inspection team.

9.1 Announced inspections

The LDoH should engage the provincial Department of Public Works to address the

poor condition of buildings and lack of space experienced by health care facilities

especially at Ellisras and Messina hospitals as well as at Bela-Bela and Namakgale

clinics. Furthermore, an audit should be conducted of the state of health care

facilities in the entire province to eradicate all dilapidated physical structures. An

action plan must be in place by 31 March 2015.

The LDoH should engage the provincial DPW to address the shortage of doctors’

accommodation at Messina Hospital. In addition, the LDoH should explore the

possibility of an incentive programme aimed at offsetting and cushioning the property

costs in case of doctors requiring to acquire own property in order to encourage their

recruitment and retention. An action plan must be in place by 31 March 2015.

38

There is a need to replace the X-Ray equipment and Surgical lights at Ellisras

Hospital to ensure sustained quality service delivery. In addition, the Department

should develop a Medical Equipment Management Plan to ensure timeous

procurement and regular maintenance of such equipment at all health facilities. A

plan of action must be in place by 31 March 2015.

The LDoH should ensure that an electronic information system is in place at all the

inspected health care facilities, which is linked to the MSD’s electronic ordering

system to ensure speedy processing of the requisition of medical supplies. An action

plan must be in place by 31 March 2015.

A system should immediately be put in place which is liked to performance

management to ensure that District Offices visit health care facilities, especially

clinics, monthly as required by the Handbook for Clinic/CHC Managers. In addition,

District Hospital Pharmacists should conduct an audit of the extent of shortage of

medicines and medical supplies at the facilities as well as the key contributory

factors. In this regard, a plan of action must be in place by 31 March 2015.

The LDoH should also immediately ensure that the pharmaceutical license of the

MSD is renewed as required by the SAPC to ensure that the operations of the depot

are legal and in line with section 22 of the Pharmacy Act, 1974.

Security measures should be improved at all health facilities’ storerooms and/or

pharmacies by augmenting existing measures with electronic equipment and

dedicated security officials to control authorized access and conduct searches. Plan

of action must be in place by 31 March 2015.

The LDoH should urgently investigate the veracity of the allegations of malpractices

relating to conduct of the Nurse-in-Charge reported at Messina Hospital.

The LDoH should ensure that DHP are in place especially in the Capricorn, Mopani,

Sekhukhune and Vhembe districts in line with the provisions of the NHA. These

DHPs should be developed in consultation with the health care facilities and then be

sufficiently disseminated to all the health facilities.

9.2 Unannounced Inspections

Outside signage for Helene Franz Gateway Clinic that is visible from the main road

should be erected immediately by September 2014. Furthermore, the LDoH should

engage the local municipality to augment the outside signage of health facilities with

direction signs to improve their accessibility.

Training should be provided to the staff in the necessary protocols of patient care and

customer care especially Batho Pele. Training programme must be in place by 31

March 2015.

The LDoH should address the concerns of waiting time through consultation

processes in line with Batho Pele (In this regard, a plan of action must be in place by

31October 2014).

39

All facilities should be equipped with functional and sufficient air-conditioning

systems. A plan of action must be in place by 31October 2014

Provision should be urgently made for additional beds at Messina Hospital.

The records management system at Ellisras Hospital should be overhauled to

improve retrieval of patients’ records and also comply with the OHS regulations. A

plan of action must be in place by 31 October 2014. In addition, its fire extinguishing

equipment should be urgently serviced.

A system should immediately be in place to ensure feedback or action following

receipt of any complaint or suggestion lodged.

Adequate parking should be provided for members of the public at both Namakgale

and Bela-Bela clinics.

10. CONCLUSION

The inspections on the availability of medicines and medical equipment in the Limpopo

Provincial hospitals and clinics have established challenges which need to be resolved to

improve health care. Critical issues identified related to the unavailability of certain

medicines and poor maintenance of medical equipment at most inspected health facilities.

Other issues identified related mainly to insufficient accommodation for doctors especially at

Messina Hospital and infrastructure such as poor condition of buildings. It is hoped that the

recommendations will assist the LDoH in ensuring that quality health care is provided at the

inspected health care facilities.

11. ACKNOWLEDGEMENT

The PSC would like to express its appreciation for the cooperation received from the officials

of the Department in all the visited sites. It is the view of the PSC that the officials were

appreciative of the importance of the inspections in supporting the work of government in its

key objective for a long and healthy life for all South Africans.

40

A LISTFACILITIESVISITED AND OFFICIALS THAT WERE ENGAGED ANNEXURE A

Name of Institution Date Names and designation of interviewed personnel Inspection Team Members

Marishane Clinic 14/10/2013 Sehlangu EM

Mphelane ML

Commissioner Mawasha

Ms Thembekile Makhubele

Mr Martin Chale

Ms Mmapeu De Jenga

Mr Bongani Ndlovu

Ellisras Hospital 15/10/2013 Mathivha M (Hospital Pharmacist)

Moloisi KP

Matjiu C

Seefane DJ (Acting clinical manager)

Makholwa MR

Khunou DH

Bela-Bela Clinic 15/10/2013 Ms Thembekile Makhubele

Mr Martin Chale

Ms Mmapeu De Jenga

Mr Bongani Ndlovu

Namakgale Clinic 16/10/2013 Ms Maake (professional nurse) Commissioner Mawasha

Ms Thembekile Makhubele

Mr Bongani Ndlovu

Messina Hospital Dube A (Head of the Institution) Commissioner Mawasha

Ms Thembekile Makhubele

Mr Bongani Ndlovu

Helene Franz Gateway

Clinic

18/10/2013 Commissioner Mawasha

Ms Thembekile Makhubele

Mr Bongani Ndlovu

District Managers 30/10/2013 Maepa ML

Kgaphole NP

Baloyi SE

Mongwe WM

Moetlo GJ

Sirwali NR

Ms Thembekile Makhubele

Mr Bongani Ndlovu

Depot 30/10/2013 Ms Thembekile Makhubele

41

ANNEXURE B

ANNOUNCED INSPECTIONS IN THE CLINICS

Availability of medicines at inspected clinics

X Norms and standards adhered to

0 Norms and standards not adhered to

Marishane Clinic

Me

dic

ine

s

Me

dic

ine

ro

om

with

bu

rgla

r ba

rs

/lo

cka

ble

cu

pb

oa

rds

Me

dic

ines a

nd

su

pp

lies s

tock

Me

cha

nis

m f

or

em

erg

ency s

up

plie

s

Ba

tte

ry %

spa

re

glo

be

s fo

r

au

rosco

pe

s

Me

dic

ines a

s p

er

ED

L fo

r P

HC

X X X X X

Bela-Bela Clinic

X X X X X

42

Availability of medicines at inspected clinics

Namakgale Clinic M

ed

icin

es

Me

dic

ine

ro

om

with

bu

rgla

r ba

rs

/lo

cka

ble

cu

pb

oa

rds

Me

dic

ines a

nd

su

pp

lies s

tock

Me

cha

nis

m f

or

em

erg

ency s

up

plie

s

Ba

tte

ry %

spa

re

glo

be

s fo

r

au

rosco

pe

s*

Me

dic

ines a

s p

er

ED

L fo

r P

HC

X X X X 0

Helene Franz Gateway Clinic

X X X X X

43

Availability of medicines at inspected hospitals

Ellisras District Hospital M

ed

icin

es

Me

dic

ines s

up

ply

acco

rdin

g to

ST

G

an

d E

DL

: H

osp

ita

l le

ve

l

Me

dic

ines s

up

ply

acco

rdin

g to

ST

G

an

d D

L: P

rim

ary

Ca

re leve

l

Me

dic

ines a

nd

su

pp

lies a

lwa

ys in

sto

ck.

Tro

lleys w

ith

em

erg

ency d

rug

s a

nd

resu

scita

tio

n e

qu

ipm

en

t

Ph

arm

ace

utica

l T

he

rap

eu

tic

Co

mm

itte

e in p

lace

X X X X X

Messina District Hospital

X X X X 0

44

ANNEXURE C

X Norms and standards adhered to

0 Norms and standards not adhered to

Availability of medical equipment at inspected clinics

Me

dic

al e

qu

ipm

en

t

Marishane Clinic

Dia

gn

ostic s

et

Blo

od

pre

ssure

mach

ine

s

Ste

tho

sco

pe

Sca

les f

or

adu

lts &

yo

un

g

ch

ildre

n

Me

asu

rin

g tap

es

Sp

ecu

lum

s o

f d

iffe

ren

t

siz

es

Ha

em

og

lob

ino

me

ter

Glu

co

me

ter

Pre

gna

ncy test

str

ips

Em

erg

en

cy tro

lley

Oxyg

en

cylin

de

r a

nd

mask

Te

lep

ho

ne

/ tw

o w

ay r

ad

io

Tw

o w

ork

ing

re

frig

era

tors

Sh

arp

s d

isp

osa

l syste

m

Ste

riliz

ation

syste

m

Eq

uip

men

t &

co

nta

ine

rs

for

takin

g b

loo

d &

oth

er

sa

mp

les

Co

nd

om

dis

pe

nse

r p

lace

d

wh

ere

easily

accessib

le

x x x x x x x x x x x x x x x x x

Bela-Bela Clinic

x x x x x x 0* 0** x x x x x x x x 0

45

M

ed

ica

l e

qu

ipm

en

t

Namakgale Clinic

Dia

gn

ostic s

et

Blo

od

pre

ssure

mach

ine

s

Ste

tho

sco

pe

Sca

les f

or

adu

lts &

yo

un

g

ch

ildre

n

Me

asu

rin

g tap

es

Sp

ecu

lum

s o

f d

iffe

ren

t

siz

es

Ha

em

og

lob

ino

me

ters

Glu

co

me

ter

Pre

gna

ncy test

str

ips

Em

erg

en

cy tro

lley

Oxyg

en

cylin

de

r a

nd

mask

Te

lep

ho

ne

/ tw

o w

ay r

ad

io

Tw

o w

ork

ing

re

frig

era

tors

Sh

arp

s d

isp

osa

l syste

m

Ste

riliz

ation

syste

m

Eq

uip

men

t &

co

nta

ine

rs

for

takin

g b

loo

d &

oth

er

sa

mp

les

Co

nd

om

dis

pe

nse

r p

lace

d

wh

ere

easily

accessib

le

0 x x x x x x x x x 0 x x x x x x

Helene Franz Gateway Clinic

x x x x x x 0 0 x x x x x 0 x x x

46

Availability of medical equipment at the inspected hospitals

Ellisras District Hospital M

ed

ica

l e

qu

ipm

en

t

Ba

sic

eq

uip

me

nt fo

r

exa

min

atio

n o

f p

atie

nts

in

OP

D a

nd

wa

rds

Ad

ult a

nd

ch

ild e

lectr

on

ic

we

igh

ing

sca

les, m

easu

ring

rods a

nd

pe

dia

me

ters

Pro

cto

sco

pe

s

La

rynsco

pes

Pe

ak f

low

mete

rs

Glu

co

me

ters

He

am

og

lob

ino

me

ters

Lu

mb

ar

pun

ctu

re k

its

Ca

rdia

c m

on

ito

rin

g u

nit

Ge

ne

ral X

-ra

y r

oom

with

su

pin

e &

bu

cky u

nit w

ith

scre

en

ing

& ta

ble

ma

ttre

ss

Sn

elle

n c

hart

Ve

no

-pu

nctu

re s

et

Flu

id g

ivin

g s

et

A c

linic

al w

aste

sto

rag

e

Fix

ed

an

d/o

r m

ob

ile o

xyg

en

su

pp

ly

A p

riva

te a

rea

fo

r cou

nse

ling

(e.g

. H

IV/A

IDS

)

Ba

sic

eq

uip

me

nt to

co

ndu

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0 x 0 x 0 x x 0 x 0 x x x x x 0 x x x x

Messina District Hospital

0 0 0 x 0 x x 0 x 0 0 0 0 0 x 0 0 0 0 0

47

ANNEXURE D

The status on the implementation of recommendations of the PSC’s inspections conducted in 200931

Primary Health

Care Site

Recommendations Implemented Not implemented

Bela-Bela Outside signage should be displayed by April 2010. Yes

Bela-Bela Business hours should be reflected by December 2009. Yes

Bela-Bela Computers should also be provided by April 2010. Proper training should be provided to staff to enable them to effectively use the computers. (In this regard a plan of action should be in place by April 2010).

Yes There is a data capturer but not all are trained to

use the system.

Marishane Computers should also be provided by April 2010. Proper training should be provided to staff to enable them to effectively use the computers. (In this regard a plan of action should be in place by April 2010).

Yes There is a data capturer but not all are trained to use the system

Marishane Business hours should be reflected by December 2009. Yes

Bela-Bela Designated help-desks manned by suitably trained personnel and stocked with appropriate forms should be provided (In this regard, a plan of action should be in place by April 2010)

Yes No suitably trained personnel for the help desk

31 Republic of South Africa. Consolidated Report on Inspections of Primary Health Care Delivery Sites: Department of Health. 2010.