National Department of Health

Presentation to the Portfolio Committee on Health

Health in the Eastern Cape Province

30 October 2013

Historical Background

• Significant backlogs were inherited in 1994• Amalgamation of health authorities, including

two homelands• Significant levels of poverty, under-

development, large areas with poor soil, under-development of infrastructure, including health infrastructure

BACKGROUND: SELECTED DATA• PHC expenditure per capita (uninsured) was R684 on average nationally

with the average for the EC being R646 (compared to Limpopo at R589 and Mpumalanga at R571); OR Tambo spend R595 per capita – the lowest of all districts and with Nelson Mandela Metro spending R928

• Of all district health service expenditure, district hospital spending nationally constitutes 39.1%; for the Eastern Cape district hospital expenditure as a proportion of total district spending was 41.7%; 37% of district spending is on district hospitals in ORT

• PHC utilisation rate (visits per person per year) nationally was 2.6; with ORT at 2.79

• Early neonatal mortality rates in districts in the EC range from: 5.1/1000 (Cacadu) to 17.2 in NMM with ORT being at 20.8 (national average is 10.2)

• In facility under 1 mortality rate in the EC range from 2.8% in Cacadu to 16% in ORT (national average is 6.8% - calculated as a percent of all separation)

Table: Comparison of iMMR per province from 2008 - 2012

Province 2008 2009 2010 2011 2012 Eastern Cape 180.4 215.2 197.0 158.26 146.44 Free State 267.0 350.9 263.5 240.08 124.54 Gauteng 136.0 160.2 159.2 121.45 142.52 KwaZulu-Natal 183.8 194.2 208.7 186.74 160.33

Limpopo 176.6 160.4 166.7 195.51 185.80 Mpumalanga 179.8 159.4 218.6 190.13 173.76 North West 161.7 279.5 256.1 153.75 127.76 Northern Cape 274.4 251.8 267.4 191.10 149.33

Western Cape 61.8 113.1 88.0 64.81 78.64

South Africa 164.8 188.9 186.2 159.14 146.71

Report from Ministerial team’s visit to Holy Cross Hospital on 13 September 2013

• To investigate the state of affairs in Holy Cross Hospital allegations from a report written by a suspended doctor, Dr Dingeman Rijken, who was an employee of the hospital

• Find facts on allegations on state of health services in the Eastern Cape as stated in an article by TAC, Section 27 and other organisations titled:’ Death and Dying in the Eastern Cape’ ,an investigation into the collapse of a health system

• Investigate and make findings whether :– The rights of any patients were violated– Any health professional breached any professional health ethical or other code of

conduct– The conduct of management of the hospital contributed in any manner to the state

of affairs in the hospital– The oversight role of the district to the hospital was exercised adequately– The provincial support to the hospital was exercised adequately– Support services are functioning optimally– Procurement procedures are in place and compliance adherence thereof– The role supervisors played in bringing to the attention of Eastern Cape Provincial

Department of Health , National Department of Health and the Health Professions Council of South Africa, the state of affairs in the hospital

Key Findings at Holy Cross Hospital

• Lack of key pieces of equipment• Lack of consistent supply of oxygen• Poor record keeping• Poor staff attitude • Poor quality of care• Irregularities in procurement • Inadequate emergency medical services in the

Flagstaff area (ORT)

Recommendations by the team: Holy Cross Hospital

• The CEO should be suspended with immediate effect pending a full investigation into her role in respect of serious dereliction of duty, mismanagement and harm to patient care.

• The Nursing Services Manager should be suspended with immediate effect pending a full investigation into her role in respect of serious dereliction of duty, mismanagement and harm to patient care.

• Progressive disciplinary measures should be instituted against the Hospital Administrator for her role in the poor management of oxygen supply to the hospital.

• All of the above have been effected

Strengthening the supply of pharmaceuticals

• Historical challenges with the functionality of the Umtata depot

• Various attempts made to strengthen the depot over time including a plan to implement direct deliveries for hospitals.

• A chronic medicine supply tender to be awarded soon which would decongest public facilities allowing patients to receive their chronic medicines at a point closer to their home/work.

• Currently: – link between depot and NDOH to monitor stock levels at the depot.– Intervention were stocks levels are low. – District pharmacists are expected to monitor facility stock levels and

report supply problems when detected to the HOPS. – A national toll free stockout line for reporting on stock outs for

patients and health professionals.

Strengthening Hospital Management

• Provincial management has been workshopped on the key issues to strengthen hospital management in the following areas:– Governance, including clinical governance– Procurement– Financial management– Human resources management

Provision of essential equipment, ORT hospitals

• NDOH has arranged for essential equipment to hospitals in the OR Tambo district

• Equipment has been delivered to Holy Cross Hospital for example

Strengthening services in OR Tambo District

• A Facility Improvement Team from the NDOH has been working in the district for the past 18 months (focusing on strengthening infrastructure, and quality improvement)

• The provincial management, District Management Team and the District Clinical Specialist Team have also developed an action plan to strengthen services in the district as a whole

ORT Action PlanOR TAMBO ACTION PLAN [18 OCTOBER 2013]What will improve the district indicators? How? And by when? Short term and long term?Area Problems Root cause Activities/Actions Responsibility Time frameHuman Resource Inadequacies in

management, leadership and accountability

Management in acting state;Managers and supervisors spend too much time in meetings;Participation of clinical and nurse managers in decision-making tends to be limited to their respective hospitals not the DHS Long delays in filling of posts for medical staff, nursing staff and identified critical posts;No approved organogram

Fast track filling of vacant posts of hospital managers;Reduce meetings, coordinate national & provincial support and increase implementation/ supervision time;Establish a Clinical Governance Forum [inclusive of clinical managers and nurse managers] Filling of critical posts Motivate for an updated organogram

Ms Nyikana and Ms JaraDM DM GM:DHS, DM, Ms Jara and Ms Nyikana GM: DHS; GM: HR

End November End January End November

High vacancy rate

- Lack of funding as budget is aligned to ‘warm bodies’

- NHI Pilot site not given a priority

- Centralization of appointment at Provincial level

- Difficulties in

attracting & retaining health professionals in rural areas (doctors, pharmacies, PNs)

- Motivate for funding for vacant posts

- Proper allocation

of resources- Decentralisation

of delegations for appointments according to organogram (up to L12);

- Implementing a 12 month-long block advert for critical posts especially doctors, nurses, pharmacists etc;

- Recruitment of foreign health professionals e.g. from Cuba for the district;

- Strengthen specialist outreach & support from the NMAH and NGOs

GM: HR CFO GM:HR GM:HR GM:HR CEO:NMAH; GM:DHS; DM

End November April 2014 End November End November April 2014 End November

Financial Support Misalignment of planning and budgeting

Lack of integration between the budget allocation and planning (DHP)

Proposal for integrated planning & budgeting processes Proposal for additional financial resources based on plans to ensure full functionality of district hospitals and PHC

District ManagerProvincial NHI ManagerDr Chitha and Dr Bongsha District Manager

31 January 2014 End November 2013

Revise the 2014/15 DHP and set realistic targets and priorities

District Manager

End October 2013

Review the NHI conditional grant and prioritise

NDOH NHI OfficeProvincial NHI coordinator andDistrict Manager

End October 2013

Supportive Work place/ environment

Minimal/Ineffective supportive supervision at all levels from Facility level at PHC and District hospital

- Non-compliance to policies & procedures

- Lack of accountability

Streghthen facility and subdistrict care coordination;Implement a coaching and mentoring programme for identified the management/ supervisory cadre and include-Revive work ethics and code of conduct-Continuous monitoring of compliance-Implementation of disciplinary measures

Provincial OfficeDMT; Sub district Manager, All Programmes Manager, CEO; NSM, Programme Manager, Clinic Supervisor, Operational Manager

November 2013 October 2013

Inadequacies in available skills and competencies

Mismatch between job description and incumbentLook at soft skills; have qualification but not skilled enough.

Implementation of skills acquisition program;Implement a focused coordinated training programme;Implement Mentoring and coaching programmeStrengthen performance management and development system

Facility manager Skills development facilitator, O.M., Area manager NSM, Administrator clinical manager, Sub-district manager and District Manager

31 January 2014

Staff attitudes Unpaid benefitsPoor working conditionsNon commitment of employees to their jobs

Follow up for unpaid benefits Provision of the tools of trade (Material , Financial and policies and procedures), Staff performance management; Explore alternative mechanisms to motivate staff

Hospital manager Sub- District ManagerDistrict Manager

30 November 2013 31 March 2014 31 January 2014 31 March 2014

Deployment and management of Dr, including sessional Drs

Weak systems of managing doctors including sessional doctors Doctors roster not monitored

Strengthen supervision and deployment mechanisms for doctors Implement close monitoring / supervision of sessional doctors

Senior Manager: NursingSenior manager: District Hosp MgtIHRM Hospital ManagersClinical ManagersSub –District Managers

30 November 2013 November 2013

Drug management Drug stock outs (SOROL, vaccines, Contraceptives, etc)

Poor drug management systems

Management/ monitoring of stock levelsContinuous training of facility managers on drug management Coaching and mentoring of other health professionals Fully functional pharmacy therapeutic committee Activation of Demander codes

Facility ManagersPharmacy Directorate Pharmacists Clinical ManagerPharmacists Provincial IT & pharmaceutical directorate

Weekly Monthly Monthly 31 January 2014

Information management

Poor data quality

Limited staffing in Information Management at district office level Lack of understanding on Indicators Not using standardized registers and reporting tools No data verification and supervision

Include Information Management staffing in critical postsIntroduce District Information Management Committee Continuous training on NIDS Availability and use of standardized registers and reporting tools Validation and verification of data

Information Managers Information Managers Facility data verification committee

October 2013 October 2013 November 2013 Monthly

Community mobilization

Poor health seeking behaviour

Local practices Strengthening of WBOTsTransport availability Inter-sectoral collaboration

Sub district manager Sub District managerHospital Manager

31 March 2014 30 November 2013

Referral systems Referral not supported by services (e.g. No MOU or CHC)Self-referralsLong queues and overcrowded services

No budget supported plan Poorly developed and coordinated referral system

Review service delivery chain and strengthen referral or drainage area -Identify areas that need MOU, CHC and maternity waiting homes;- Strengthen the identified prioritised hospitals;- Strenthen specialist services in St Elizabeth Hospital and Mthatha General Hospital;- Develop, distribute and implement clinical guidelines together with the NMAH

DCST, DMT and Ms Nyikana to finalise the new service delivery platform 4 hospitals and regional hospitals

By end Nov 2013

EMS Transport Inadequate staff/capacityInadequate numbers of ambulance, especially for obstetrics

No budget supported plan Poor maintenance plans

How many ambulances needed? Obstetrics? Newborns?How many paramedics?Training

Functioning of WBOTS

Functionality of WBOTS is ineffective

Lack of transport Provision of transport

Senior manager : Fleet

31 March 2014

Supply Chain Management

Procurement of supplies and equipment is characterised by long turnaround times with negative implications for quality of care

Centralisation of delegations and budget not talking to plans and services

Decentralisation of delegations accroding to level;Use of DM and NMAH CEO and committee infrastructure to support the district

CFO and Mr Mtheleli

November 2013

Clinical governance

Poorly applied clinical protocolsInadequate or malfunctioning Equipment, and maintenanceShortages Drugs and suppliesNo Clinical coordination and mentorshipWeak and inappropriately led Mortality Reviews

High turnover of clinicians Lack of supervision and clinical coordination Poorly developed clinical supportive servicesLack of skills

Re-vitalize Regional coordination forum and do oversight to quality of facility reviews Create clinical governance forums to take appropriate actions at facility and subdistrict levels;Ensure lessons are learned and corrective measures are implemented; Implement a clinical suport service development strategy

Mrs MakwediniDCST DCST, DMT and CMOs

November 2013

Provincial District Improvement Teams

• The ECDOH has appointed a provincial team to work with the DMT and the DCST to support ORT

• ECDOH is also in the process of establishing teams for each of the other districts

• Team leaders report to the Head of Department and the MEC

Conclusions

• Clearly there are many challenges in the EC and in ORT in particular

• NDOH with the ECDOH has a robust plan to strengthen health services in the EC and in ORT in particular