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REPORT ON A SERVICE DELIVERY

INSPECTION OF DISTRICT HOSPITALS AND

CLINICS REGARDING AVAILABILITY OF

MEDICINES AND MEDICAL EQUIPMENT AND

THE ROLE OF HEALTH DISTRICT OFFICES

DEPARTMENT OF HEALTH:

FREE STATE 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: Free State 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 ................................................................................... 3

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

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

5.2 Management of medicines ......................................................................................... 5

5.3 Management of medical equipment ........................................................................ 13

5.4 Governance of health facilities ................................................................................ 15

5.5 Challenges................................................................................................................. 16

6 KEY FINDINGS ON UNANNOUNCED INSPECTIONS ............................................. 18

7. IMPLEMENTATION OF PSC RECOMMENDATIONS .............................................. 25

8. READINESS OF THE INSPECTED FACILITIES FOR THE ROLL-OUT OF

NATIONAL HEALTH INSURANCE (NHI) .................................................................. 25

9. RECOMMENDATIONS: ............................................................................................. 26

9.1 Announced Inspections ........................................................................................... 26

9.2 Unannounced Inspections ....................................................................................... 26

10. CONCLUSION ............................................................................................................ 27

11. ACKNOWLEDGEMENT ............................................................................................. 27

ANNEXURE A: A LIST OF FACILITIES VISITED AND OFFICIALS THAT WERE

ENGAGED ............................................................................................................................ 28

UNANNOUNCED INSPECTIONS IN THE CLINICS ............................................................ 30

ANNEXURE B1: Availability of medical equipment at inspected clinics ....................... 30

ANNEXURE B2: Availability of medical equipment at the inspected hospitals ............ 32

ANNEXURE C1: Availability of medicines at inspected clinics ...................................... 33

ANNEXURE C2: Availability of medicines at inspected hospitals ................................. 35

ANNEXURE D: THE STATUS ON THE IMPLEMENTATION OF RECOMMENDATIONS

OF THE PSC’S INSPECTIONS CONDUCTED IN 2009 ...................................................... 36

Tables

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

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

Figures

Figure 1: Medicine management cycle .................................................................................................. 6 Figure 2: Availability of tracer drugs at health facilities ......................................................................... 11


Equipment and the Role of Health District Offices in the Department of Health: Free State Province ii

Pictures

Picture 1: Pharmacies of Phuthaditjhaba and Bophelong clinics with burglar doors to ensure

controlled access and safety of medicines. ......................................................................... 8

Picture 2: Medicines and medical consumables packed neatly on the shelves at Tokollo District

Hospital ................................................................................................................................ 9

Picture 3: Medicines stored in a refrigerator with controlled temperature at Brentpark Clinic. ............ 9

Picture 4: (left) Medical waste bucket still in use at Brentpark clinic. (Right) Medical waste buckets

sealed and safely stored for safe removal by a medical waste management company. .. 10

Picture 5: (Left) Reception area at Tokollo Hospital. (Right). Neat bedding in a ward at Tokollo

Hospital. ............................................................................................................................. 18

Picture 6: The wall (left) and floor (right) at Bophelong clinic show a crack which poses a health and

safety risk. .......................................................................................................................... 19

Picture 7: The grounds of Brentpark clinic need proper gardening. .................................................. 19

Picture 8: Cluttered sluice room used to store wheelchairs and other essentials. ............................ 20

Picture 9: A store room for medicines is also used to keep food for staff. ........................................ 20

Picture 10: The water tank at Brentpark clinic which needs to be installed. ........................................ 21

Picture 11: Poster in Sesotho and depicting tips on how to wash hands to promote hygiene. ........... 22

Picture 12: Business hours displayed at Brentpark Clinic. .................................................................. 23


Equipment and the Role of Health District Offices in the Department of Health: Free State 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) will 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.

The inspections also 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. Generally, it was found that despite supply chain challenges, medicines and

medical equipment were largely available at the sites visited. Out of 17 PSC’s

recommendations, 16 (94%) were implemented. Based on the findings and observations, it

is the PSC’s view that the visited health facilities were ready for the roll out of the NHI.

However, they require urgent attention relating to shortages of health care professionals.

It is with 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 the Free State. 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 Free State Department of Health (FSDoH) for their

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

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


Equipment and the Role of Health District Offices in the Department of Health: Free State Province iv

LIST OF ACRONYMS

AIDS Acquired Immune Deficiency Syndrome

AO Accounting Officer

ARV Antiretroviral

BP Blood Pressure

CEO Chief Executive Officer

CHC Community Health Centre

CPU Central Processing Unit

DAP District Acquisition Plan

DDV Direct Delivery Voucher

DHP District Health Plan

DHS District Health System

EA Executive Authority

EDL Essential Drugs List

FEFO First In, First Out

FSDoH Free State Department of Health

HIV Human Immunodeficiency Virus

HoD Head of Department

MCC Medicine Control Council

MEC Member of the Executive Council

NEDLC National Essential Drugs List Committee

NEMLC National Essential Medicine List Committee

NDP National Development Plan

NDPSA National Drugs Policy of South Africa

NHA National Health Act

NHI National Health Insurance

PHC Primary Health Care

PMCC Provincial Medical Consumables Committee

PSC Public Service Commission

PTC Pharmaceutical and Therapeutic Committee

RDM Remote Demander Module

SCM Supply Chain Management

SLA Service Level Agreement

SOPs Standard Operating Procedures

STG Standard Treatment Guidelines

TB Tuberculosis

WHO Wealth Health Organisation


Equipment and the Role of Health District Offices in the Department of Health: Free State Province 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.

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 present 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.



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 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. SCOPE AND METHODOLOGY

3.1 Scope

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

and medical equipment at selected district hospitals and clinics. 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. In particular, the Thabo Mofutsanyana District was selected on the basis that it

has been identified for the pilot of the NHI.

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. The table below shows the inspected sites.

Table 2: Sites and dates of inspections

Provincial/District Office Component/Institution Date of Inspection

Provincial Office Sub-Directorate: Pharmaceutical Services 19/09/2013

Medical Depot 29/10/2013

Fezile Dabi District Office 30/09/2013

Brentpark Clinic 30/09/2013

Bophelong Clinic 30/09/2013

Tokollo District Hospital 01/10/2013

Thabo Mofutsanyana District Office 07/10/2013

Elizabeth Ross District Hospital 08/10/2013

Phuthaditjhaba Clinic 08/10/2013

Bluegumbosch Clinic 09/10/2013

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 and the role of the health district offices in this regard.

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 set the scene for the inspections.

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:

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



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

The findings of the announced inspections are presented into key thematic areas, which are

the management of medicines and the management of medical equipment. This will be

preceded by a contextual background.

5.1 Contextual background

In order to set the scene of the inspections and understand the extent of the problem, the

inspection team held a meeting with the Manager: Pharmaceutical Services of the Free

State Department of Health (FSDoH) on 19 September 2013. The purpose of the meeting

was to obtain an overview of the province’s DHS as well as information regarding policies

relating to the Primary Health Care (PHC) services, especially with regard to the distribution

of medicines and the management of medical equipment.

It emerged during discussions that the procurement of pharmaceuticals, medical

consumables and medical stationery used by district hospitals and clinics in the Free State

province is handled by an appointed Medical Depot (who procures such from the medical

suppliers). The inspection team was provided with a copy of the Service Level Agreement

(SLA) between the Medical Depot and FSDoH, which was reviewed and signed on 01 July

2013 and 13 August 2013 respectively. Furthermore, it emerged that District Offices must

develop District Health Plans (DHPs) as required by section 33 (1) of the National Health

Act, 2003 (NHA). It was found that the DHPs, which include a situational analysis on the

burden of disease as well as mitigating strategies, were developed and presented to the

Member of the Executive Council (MEC) of Health in the province in line with the NHA.

Furthermore, it was found that District Offices would consolidate and forward their orders in

terms of pharmaceuticals, medical consumables and medical stationery directly to the

Depot. However, an arrangement has been made for direct procurement by district hospitals

from the suppliers, which is in line with the Minister’s announcement of direct procurement

from suppliers7. The details of this arrangement are contained in paragraph 5.2.2.

The inspection team was also informed that challenges were experienced with the delivery

of pharmaceuticals, medical consumables and medical stationery in the beginning of the

2013/2014 financial year due to unavailability of stock at the Medical Depot. This was as a

result of outstanding payments of ±R32 million from the department to the suppliers for the

7 Republic of South Africa. Department of Health. Strategies to improve Performance in South Africa to ensure Universal

Health Coverage, Quality Care, Hospital Effectiveness and Affordability of Health Care. 2013



previous financial year, 2012/2013, who subsequently withdrew their services to deliver

stock at the Medical Depot. Although the suppliers were later paid after funding was

obtained from Provincial Treasury, the delayed payment was in contravention of Treasury

Regulation 8.2.3 which provides that “… payments due to creditors must be settled within 30

days from receipt of invoice”. It also emerged that some of the suppliers were no longer

willing to do business with the Medical Depot following the crisis. As result, the Medical

Depot experienced shortage of stock which further delayed deliveries to the health facilities.

The inspection team was informed that the situation had since improved and at the time of

the inspection, there were very few cases of shortage of medicines.

With regard to medical equipment, the inspection team was informed that the Provincial

Head Office is responsible for the procurement of equipment from minor to major assets.

Health facilities within districts submit their needs to the District Offices which are

consolidated and submitted to the Provincial Head Office, whereas the provincial and tertiary

hospitals submit their needs directly to the Provincial Head Office for acquisition.

Furthermore, the inspection team met with senior officials of both the Fezile Dabi and Thabo

Mofutsanyana District Offices on 30 September 2013 and 07 October 2013 to determine

their role in ensuring that medicines and medical equipment are available at health facilities.

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

supervisors should visit these facilities monthly to oversee operations and offer support8. In

addition, the inspection team visited the selected health care facilities within these districts to

determine the availability of medicines, medical equipment and the maintenance thereof as

well as the support received from the District Offices.

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. (It should be noted that for the

purpose of this report, reference to medicines includes pharmaceuticals, medical

consumables and medical stationery). In this regard, the findings on the management of

medicines are structured according to this integrated process.

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

1999.



Figure 1: Medicine management cycle

5.2.1 Product selection

National essential drug lists, together with standard treatment guidelines, serve as the basis

for formal education and in-service training for health professionals and for education about

medication use for the public9. 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 senior officials at both Fezile Dabi and Thabo Mofutsanyana District

Offices, it emerged that Pharmaceutical and Therapeutic Committees (PTCs) were

established at Provincial, District and hospital levels. The main objective of the PTCs is to

“ensure the rational, efficient and cost-effective supply and use of drugs”10. To this end, the

PTC’s function includes the identification of new drugs for possible inclusion on the EDL

based on consideration of scientific evidence of efficacy, substantial safety, risk/benefit ratio

as well as best cost advantage of the identified drug. According to the district officials, any

identified new drug or list of recommended new drugs is then considered by the District PTC.

Once agreed, the drug or list of drugs is consolidated and submitted to the Provincial PTC

for support, and subsequently forwarded for final consideration by the NEDLC. PTCs at

provincial and district levels are expected to hold meetings quarterly, whereas the hospital

PTCs should meet monthly. Copies of the minutes of the relevant District PTCs were

produced, which confirmed the frequency of meetings. Furthermore, the minutes of the

9 Jane Hutchings et al. United States of America. The Role of Essential Medicine Lists in Reproductive Health. December

2010. Volume 36. 10 Republic of South Africa. Department of Health. National Drug Policy of South Africa. 1996.

Product

selection

Rational use,

monitoring and

evaluation

Distribution and

storage

Procurement

Management support:

Information system

Organisation/staffing

Budgeting

Training



provincial PTC dated 29 May 2013 confirmed the deliberations on possible addition of new

medicines on the EDL at this level. It is the view of the PSC that product selection is well

institutionalized and contributes effectively toward the availability of medicines at health care

facilities.

5.2.2 Procurement

In terms of the general principle of the SLA between the FSDoH and the Medical Depot all

pharmaceuticals, medical consumables and medical stationery used in facilities falling under

the control of the FSDoH must be procured from or through the Medical Depot unless

permission to buy out such items has been granted to the facility. It was confirmed by

officials at Fezile Dabi and Thabo Mofutsanyana that all clinics and CHCs place their orders

monthly which are consolidated at district level for submission to the Medical Depot. The

inspection team was also informed that facilities such as District hospitals may in addition to

ordering from the Medical Depot through the district offices, use the Direct Delivery Voucher

(DDV) and “buy-out” methods. In terms of the DDV method, the order is placed through the

Medical Depot by the District hospital, but the medicines are delivered directly to the

hospitals by the supplier and/or pharmaceutical company. The “buy-out” method means the

hospital orders directly from the suppliers or pharmaceutical companies on a quotation

basis. However, the “buy-out” method is only allowed in the case of an emergency and

subject to prior permission by the FSDoH. This was to ensure that items were ordered in

accordance with the SLA and also based on the EDL. Officials at district hospitals confirmed

that they took advantage of the DDV and “buy-out” methods when necessary to obtain

medicines. This level of flexibility allows for efficient acquisition of urgently needed medicines

at the health facilities, and thereby ensuring stock availability.

5.2.3 Distribution and storage

Distribution: According to the SLA the Medical Depot is responsible for the delivery of

stock to facilities within four (4) weeks of the receipt of orders from individual facilities.

During the visit to Fezile Dabi and Thabo Mofutsanyana, the inspection team learned that

delays were experienced with deliveries of orders in the beginning of the 2013/2014 financial

year. The longest delay experienced was eight weeks as reported by Thabo Mofutsanyana

and this was mainly due to the financial challenges raised by the Provincial Office.

Inspections at the Medical Depot also found that a serious shortage of stock was

experienced in the beginning of the 2013/2014 financial year due to the late payment of

suppliers by the FSDoH, which resulted in most of the suppliers no longer willing to do

business with the Department and deliver stock at the Depot. The inspection team also

learned that other challenges arose after the payment to suppliers was made. For instance,

the Medical Depot, which is servicing a total of 423 facilities in the province, battled to

arrange for deliveries of ordered stock within the set timeframes as per the SLA due to

insufficient staff capacity in dealing with the resulting backlog of deliveries. Although

remunerated overtime was instituted, this was only for a short period due to financial

constraints. The inspection team was, however, informed by officials at Fezile Dabi that

some of their staff were made available to assist the Depot with the sorting of ordered stock

according to specific facilities. This expedited the packaging process and made huge

improvement in addressing the backlog.



Another challenge the Depot experienced in the beginning of the financial year was that the

newly appointed contractor for delivery of stock to all facilities in the province was unfamiliar

with some of the routes. This, therefore, resulted in further delays of deliveries to health

facilities.

The above challenges of late deliveries of ordered items were corroborated by all the visited

hospitals and clinics in both districts. For example, Tokollo District Hospital mentioned that it

had to arrange its own transport to fetch ordered stock at the Depot due to the reported

delays in deliveries.

Storage: Standard Operational Procedures (SOPs) were found to be in place to ensure

control of access to the facilities’ pharmacies, safety and appropriate labelling of medicines

and medical consumables. The inspection team observed at the clinics and hospitals visited

that the pharmacies were always locked and notices displayed prohibiting unauthorized

access, and as such, there was generally compliance with the SOPs.

Picture 1: Pharmacies of Phuthaditjhaba and Bophelong clinics with burglar doors to ensure controlled access and

safety of medicines.



The inspection team also observed that all medicines and medical consumables were neatly

packed on the shelves with appropriate labelling for easier identification.

Picture 2: Medicines and medical consumables packed neatly on the shelves at Tokollo District Hospital.

Furthermore, the temperature in all pharmacies and refrigerators used for storing certain

medicines was appropriately controlled to sustain the quality of the medicines.

Picture 3: Medicines stored in a refrigerator with controlled temperature at Brentpark Clinic.



Proper stock control measures should be put in place to ensure safety of medicines and

medical supplies as well as to minimise discrepancies. According to the NDPSA, all

unwanted and expired drugs, medical supplies and associated waste should be disposed of

promptly, efficiently and safely. It was observed that the inspected clinics and hospitals were

using stock cards which were regularly updated based on stock availability and to inform

future orders. The inspection team further observed that all health facilities were using the

“first expired, first out” (FEFO) principle in identifying outdated medicines on their shelves to

ensure quality of medicines in keeping with the provisions of the NDPSA.

Furthermore, the inspection observed that the necessary waste buckets were provided for

safekeeping of medical waste. It was also found that once the buckets were full they were

sealed and safely placed where they were later collected by a medical waste management

company for incineration.

Picture 4: (left) Medical waste bucket still in use at Brentpark clinic. (Right) Medical waste buckets sealed and safely

stored for safe removal by a medical waste management company.

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. According

to the guidelines for the district pharmacist in the province, clinics must be visited monthly by

the supervisor and a written record of the supervisor’s visit should be left with the clinic. The

purpose of the visits is to oversee the operations and provide pharmaceutical support,

especially in ensuring that the Standard Treatment Guidelines (STGs) are strictly followed by

the nursing staff. Although officials at the District Offices informed the inspection team that

visits were being regularly conducted, evidence of such visits by pharmaceutical officials

could not be found during examination of the visitors books at inspected facilities. Even

though the nursing staff at Brentpark and Bophelong indicated that the clinics were receiving

regular pharmaceutical support, the lack of evidence of these visits points to a challenge in

this regard. It was not in keeping with the Handbook for Clinic and CHC Managers. It was,

however, heartening to observe that the nursing staff at the visited facilities was guided by

the STGs in ensuring that patients were informed of the correct use of medicines including



providing them with accurate information on any dietary considerations whilst taking the

prescribed treatment.

Monitoring and evaluation: District Offices should manage the availability and safe use of

medicines at health facilities. The inspection team observed that there was a system called

Tracer Drugs used in the province for monitoring the availability of medicines at health

facilities. In this regard, a checklist has been developed by which a sample of essential

medicines is selected and monitored for availability at the health facilities. Based on the

checklist, reports were produced indicating which medicines were out of stock. Such

reporting took place weekly, monthly and quarterly and was linked to reporting against the

DHPs in line with the National Health Act, 2003. According to the DHPs for Fezile Dabi and

Thabo Mofutsanyana, the target for availability of medicines and medical consumables was

95%. The inspection team’s analysis of the quarterly reports of the two districts indicated that

most clinics in Fezile Dabi had coverage of 98% and in particular, the Tokollo hospital

achieved 99%, while clinics in Thabo Mofutsanyana and Elizabeth Ross hospital had

coverage of 95% and 99% respectively.

Figure 2: Availability of tracer drugs at health facilities

The foregoing performance suggested that the District Offices maintained consistent

availability of medicines at the facilities despite the challenges experienced in the beginning

of the 2013/2014 financial year. Upon enquiry with officials at Fezile Dabi, it emerged that

this was not entirely as reported. The District held the view that the small sample of

essential medicines utilized for monitoring availability might have presented a skewed

picture. It was also indicated that health facilities which experienced a shortage of certain

medicines were able to borrow from other facilities which had sufficient reserves of such

medicines. This ensured uninterrupted services whilst the challenge at the Depot was being

attended to. Having buffer stock at facilities was in line with the NDPSA.

Furthermore, the inspection team was informed by the nursing staff at inspected facilities

that there was no serious shortage of medicines. For instance, at Bophelong clinic the

nursing staff indicated that only Ferrous Sulphate (to be administered in the case of iron

deficiency in pregnant women) and Pentaxim (immunization for babies between ages of 2 to

4 months) were in short supply. However, the inspected facilities indicated that the situation

had improved following the payment of suppliers by the FSDoH as earlier indicated.

95%

98%

99%

95%

99%

93%

94%

95%

96%

97%

98%

99%

100%

Target for tracerdrugs

Fezile Dabi Clinics Tokollo Hospital ThaboMofutsanyana

Clinics

Elizabeth Ross



One of the functions of the PTC is the regular monitoring of medication errors and adverse

drug events at health facilities. The inspection team was informed that medication errors

may arise in instances of misdiagnosis of an illness. Scrutiny of the minutes of the provincial

PTC dated 28 August 2013 showed that a case of an adverse drug event was dealt with and

subsequently reported to the Medicines Control Committee (MCC) for further attention. At

Tokollo hospital the PTC in May and July 2013 dealt with cases of medication errors.

5.2.5 Management support

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

functioning of facilities.

Information 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 at the depots. The objective is to ensure the prompt,

efficient, timely and equitable distribution of essential drugs and medical supplies to all

health care institutions 11 . During inspection at the Medical Depot the inspection team

observed that the Medical Depot uses the Medfas system.

Furthermore, the inspection team obtained a copy of the Health Notice No. 5 of 2009 in

which the FSDoH directed all health care facilities in the province to use a computerized RX

Solution as from 1 November 2009 to capture pharmaceutical stock. The system has other

key functions such as determining stock levels and expiry dates as well as forecasting of

needs for sufficient ordering purposes. It was, however, observed during inspection that not

all visited facilities were using the system. Only Bluegumsbosch clinic and Tokollo and

Elizabeth Ross hospitals were using the system and was linked with the Medfas system at

the Medical Depot. The linkage is through a Remote Demander Module (RDM) software

programme, which was mainly used for ordering stock. The inspection team was informed

that the roll out of the RX Solution in all facilities was impeded by budgetary constraints.

The staff at Tokollo hospital also informed the inspection team that the computer on which

the RX Solution is installed, was being used for administrative duties as well. This was due

to a shortage of computers and network points. Tokollo hospital provides a 24 hour service

and regularly requires uninterrupted access to the RX Solution for optimal utilisation of the

system in effectively managing availability of medicines, including distribution of medication

in the wards. The dual use of the computer at the hospital meant that critical pharmaceutical

functions could not be performed while the computer was being used for administrative

duties, which impacted negatively on effective and efficient service delivery.

Other inspected clinics were still using the manual stock card system for ordering purposes

and stock control. This system was time-consuming and impacted negatively on service

delivery as it took days before the clinics could establish the appropriate stock levels to

inform ordering of new items. Previous inspections of the PSC emphasized the need for the

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



FSDoH to provide health care facilities with the requisite information technology (IT)

equipment in order to ensure the improved quality of service12.

Training: Training is important to ensure that employees are knowledgeable about what is

expected of them and also to keep abreast of new developments in order to provide quality

services to their clients. Although no evidence of specific training support with regard to

issues of medicine management was found at the inspected facilities, the inspection team

was shown a copy of a compact disc on drug management at Fezile Dabi. It was, however,

observed that other training support was provided by the District Offices. For example,

evidence was found of training relating to mental health, HIV/TB management, foetal alcohol

syndrome, lung diseases, infection control, and health and safety issues at Tokollo,

Elizabeth Ross and Bluegumbosch hospitals. Road shows on substance abuse and an anti-

rape campaign were also conducted. These training interventions were proactive measures

as they were focused on prevention rather than cure. They were also in keeping with

government’s commitment to increase life expectancy, decrease maternal and child

mortality, combat HIV and AIDS and decrease the burden of disease from TB through

education to ensure informed choices by the citizens. The District Offices should be

commended in this regard.

Staffing: In terms of the NDPSA, pharmacists play the critical role of managing medicine

supply in both hospital pharmacies and clinics. The inspection team was informed by visited

facilities that there is a need for additional capacity considering that there are only two (2)

pharmacists responsible for overseeing 28 clinics in the province. Similar concerns of

capacity constraints at health facilities were previously highlighted by the PSC during its

inspections of health care facilities in 200913. It is the view of the PSC that staff shortages

often result in employees being overworked and thus leading to low staff morale, which may

impact negatively on the quality of service.

5.3 Management of medical equipment

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

health care.

Procurement: The District Offices informed the inspection team that the procurement of

medical equipment is centralised at the Provincial Head Office. All health facilities were

expected at the beginning of the new financial year to submit their annual needs to the

relevant District Offices for consolidation into District Acquisition Plans (DAPs). The District

Offices were accordingly expected to make budget provisions based on the DAPs and

forward the plans to the Head of the Department (HoD) for approval. Once the plans were

approved and the budget allocated, the purchasing of equipment was dealt with in terms of

the applicable provincial Supply Chain Management (SCM) procedures. Upon receipt of an

order to purchase, the approved supplier may then deliver the consignment to the relevant

facilities. The inspection team observed that all the facilities adhered to the process. The

inspection team was, however, informed at Elizabeth Ross Hospital that delays in the

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

Delivery Sites: Department of Health. 2010. 13 Republic of South Africa. Public Service Commission. Consolidated Report on Inspections of Primary Health Care

Delivery Sites: Department of Health. 2010.



ordering of medical equipment were experienced during the 2013/2014 financial year due to

the late approval of the acquisition plan by the HoD.

Quality of medical equipment: It emerged that a Provincial Medical Consumables

Committee (PMCC) has been established which held its meetings quarterly. The role of the

PMCC was to deliberate on complaints received from facilities relating to poor quality of

equipment from certain suppliers in order to inform future procurement processes. Facilities

were required to document these on a standard form for consideration by the PMCC.

However, Elizabeth Ross hospital indicated that in some instances the equipment received

was of poor quality. The hospital attributed the poor quality of equipment to the SCM process

of selecting the cheapest quotations. Similar concerns were also raised by the

Phuthaditjhaba and Bluegumbosch clinics. At Bophelong clinic the nursing staff complained

that the Vicidex haemoglobinometer provided unreliable readings even though it was still

new. In response, the Fezile Dabi District was surprised to learn that the clinic was still using

the said item which the District no longer procured. The foregoing points to weaknesses in

the Department’s monitoring and audit processes, especially the effectiveness of the PMCC,

to ensure that facilities report on poor quality items so that these were no longer procured

from affected suppliers in future.

Asset control: Medical equipment involves the use of state funds and must be safeguarded

to ensure accountability. At all facilities visited, the inspection team found that the function of

asset control is centralised at the District Offices. It was also found that the acquired

equipment is captured on the asset register which is updated following an asset audit on a

monthly basis.

Maintenance of equipment: During interaction with the Provincial Head Office, the

inspection team was informed that there are no provincial guidelines for maintenance of

equipment. The District Offices indicated that they were responsible for maintenance of

equipment such as baby incubators and autoclaves. Facilities were expected to make a

requisition for the maintenance of equipment by the contractors by completing a prescribed

Form H24. At Elizabeth Ross and Tokollo hospitals, the inspection team was provided with

copies of their medical equipment maintenance plans which showed that the last inspections

of equipment were conducted on 10 September 2013 and 20 September 2013 respectively.

Amongst others, the aforementioned plans reflected the following details:

Type of inspected equipment;

Model/make;

Serial number;

Life span of equipment;

Its condition;

Where it is located;

Frequency of service required; and

Recommendations.

The visited clinics and District Offices did not provide the inspection team with proof of

maintenance of their medical equipment. However, most of them indicated that they did not

have challenges with medical equipment. Only Bophelong clinic raised concerns that the



electronic Blood Pressure (BP) machine required maintenance as it often provided incorrect

readings especially after prolonged usage. As a result, the clinic would revert to the manually

operated BP equipment. Although no serious challenges of misdiagnosis have been

reported at the clinic, it was a concern to the nursing staff that they always have to confirm

the readings with the manually operated equipment. It also raised a concern of value for

money to have equipment which cannot be utilised.

Disposal of medical equipment: The inspection team was informed that the whole process

of disposal of equipment was handled by the District Offices. According to officials at the

District Offices the status of identified items was first verified by a team of technicians from

the Provincial Health Office before the certificates could be issued for the items to be

declared redundant or obsolete. Once the approval was granted the asset controllers from

the District Offices would take the process forward. All the visited facilities indicated that they

submitted lists of items identified for disposal to the District Offices for consolidation and

further handling. The inspection team did not find any obsolete equipment at the visited

facilities.

5.4 Governance of health facilities

Since public funds are used to provide public services, 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. In this regard, 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 clinic 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 should be represented on the hospital board 14 . During interaction with the District

Offices, the inspection team was informed that hospital boards have been established, and

were convening regular meetings.

At Tokollo hospital, the inspection team was welcomed by a member of the hospital board

who apparently had earlier held a meeting with the CEO of the hospital. The board member

expressed great appreciation for the support the board was receiving from the hospital in

discharging its function. The CEO of the Tokollo hospital also mentioned that the members

of the hospital board were sometimes summoned to the provincial Portfolio Committee of

Health and further reported to the MEC if they were not satisfied about certain issues. The

foregoing suggests that a positive relationship exists between the hospital and the board,

which engendered confidence amongst the community that the hospital was responsive to

its inputs in ensuring the quality of service at the hospital.

During discussion with management at Tokollo and Elizabeth Ross District Hospitals, the

inspection team was informed that the function of the hospital board is to relay the

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



complaints of the community to the hospital management regarding issues such as

cleanliness, waiting time and availability of equipment and medicines. In addition, the

hospital board also informed the members of the community about new developments at the

hospital. Minutes of the Tokollo hospital board dated 22 August 2013 were scrutinized, and it

was found that the community provided inputs on issues relating to patient care, safety and

water amongst others.

The inspection team further analysed the minutes of the Elizabeth Ross hospital board held

on 04 July 2013. According to the minutes, the chairperson of the hospital board had a

meeting with traditional leaders and councillors to inform them about the stolen computer

Central Processing Unit (CPU) from the Radiology Department of the hospital. In addition,

three (3) board members attended a community meeting on 06 June 2013 at Paballong

Village to give feedback on developments and challenges at Elizabeth Ross hospital. This

implied that the Tokollo and Elizabeth Ross hospital boards were operational in keeping with

the constitutional principle of public participation.

Clinic Committees: Clinic committees are essential for consultation with the communities

on health improvement issues and also to act as a link with the Department. The inspection

team was informed by the District Offices that clinic committees have been established and

functioning as required. At the Phuthaditjhaba and Bluegumbosch clinics, the inspection

team interacted with some of the members of clinic committees. It emerged during

discussion with them that committees were operational and held their meetings monthly.

Furthermore, the committees convened meetings when there were issues raised via

suggestion boxes that needed urgent attention. For instance, the suggestion/complaint

boxes were opened once a week by two (2) clinic committee members and the Operational

Manager of the clinic.

Minutes of the committees were also examined. The inspection team observed that critical

issues dealt with by the committee for Bluegumbosch clinic related to the long waiting

periods, the need for extended hours, a relief system for lunch breaks and shortage of

nursing staff and security officers. The foregoing issues were apparently identified during

patient satisfaction surveys conducted by the clinics. A complaint lodged through the

complaints box against a doctor was also dealt with. According to the nursing staff the

aggrieved patient was invited to make a representation in the case and the matter was

resolved.

Furthermore, the inspection team observed that clinic committee members also assisted with

cleaning and queue marshalling. A register was examined at Phuthaditjhaba clinic wherein

committee members signed every day and recorded what they have done. This ranged from

opening of the windows when the clinic operations commenced to discussing the theme of

the day or week with patients. The foregoing is consistent with the developmental state

agenda as espoused in the National Development Plan (NDP) and was also in keeping with

government’s slogan which says “together we can do more”.

5.5 Challenges

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

service delivery at the inspected facilities:



Staff shortage: It emerged that there was generally a staffing challenge of professionals at

most of the visited facilities. Considering that primary health care is primarily nurse driven,

shortage of nursing staff is likely to affect the quality of health care at the facilities if not

addressed. The inspection team was informed by the Manager: PHC at Fezile Dabi District

that most facilities were still operating on old post structures. It was, however, comforting to

learn that the MEC was in the process of reviewing the structures to align these with the

demands placed on the facilities arising from the general population increase in the province.

At Bophelong clinic, the inspection team was informed that there was a need for additional

professional nurses due to the high patient turn-out experienced by the clinic. The nursing

staff indicated that the clinic has six (6) professional nurses, who often attended to

approximately 200 patients per day. Although this number meant one (1) nurse attended to

33 patients per day and seemed sufficient based on the nationally approved nurse to patient

ratio of 1:40, the nursing staff found this to be inadequate. The inspection team was

informed that the staff was insufficient as some of the nurses have to take leave, attend

meetings or training. This results in the available nurses being inundated with work, and has

impact on the quality of services at the clinic.

According to the CEO of Tokollo hospital there was a high labour turnover especially of

young professionals as most felt that there was nothing attractive in and around Heilbron to

encourage their long-term stay. This was due to lack of amenities such as schools,

recreational facilities and accommodation in Heilbron, which is predominantly a farming

area. The CEO further mentioned that the hospital was forced to utilize some of the staff in

other functions in which they were not sufficiently trained. Utilization of staff in different

functions promotes learning of new skills, and was in keeping with good practices such as

job rotation or job enrichment. While this may serve as a short term solution to the hospital’s

capacity problems, it is the view of the PSC that the arrangement may cause burnout with

the potential to adversely affect the quality of the service offered by the staff in the long run.

Thus a long term solution should be sought. Concerns of shortage of staff are worrying

especially since the PSC’s previous inspections highlighted these challenges as well as the

need to fill vacancies, particularly in the professional and pharmaceutical fields15.

Infrastructure: One serious challenge that was raised at the Thabo Mofutsanyana District

Office and visited facilities was the intermittent power failures in the area, which is serviced

by the Maluti-A-Phofung Local Municipality. This has largely impacted on the functioning of

equipment and care of drugs and medical consumables that need to be stored in

refrigerators. Furthermore, the battery for the Blood Gas Machine, which requires electricity

for recharging was eventually damaged as a result of the recurrent power failures. The

inspection team was informed that the Elizabeth Ross Hospital management had raised the

challenge of weak power supply in the area with the Local Municipality, but there had not

been any improvement. It was also found that the Elizabeth Ross Hospital’s backup

generator was damaged in July 2013 and needed replacement. Although the matter was

raised with the provincial department, approval for the replacement had not been obtained at

the time of the PSC inspections.

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

Delivery Sites: Department of Health. 2010.



Budget constraints: Lack of funds impacted on the roll out of the RX Solution information

system to all facilities in the province. At Tokollo hospital a concern was raised that the X-ray

machine had almost reached its lifespan, and needed to be replaced urgently. The cost of

replacing the equipment was estimated at one million rands, and the hospital was uncertain

as to when it will be replaced. This presents a serious challenge for the hospital in providing

quality health care. This also points to a lack of proper budget planning by the Department

as a similar challenge was experienced as indicated earlier with the non-payment of

suppliers to the Medical Depot for the 2012/2013 financial year.

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 times 16 . The purpose of unannounced inspections was to

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

6.1 Observing facilities

Condition of premises: Most visited facilities generally appeared clean and well

maintained.

Picture 5: (Left) Reception area at Tokollo Hospital. (Right). Neat bedding in a ward at Tokollo Hospital.

It was, however, observed that the Bophelong clinic’s building had a worrying crack which

further affected its floor. The crack poses a serious health and safety risk. The Department

needs to repair the observed crack urgently.

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

Transformation of Public Service Delivery, 1997.



Picture 6: The wall (left) and floor (right) at Bophelong clinic show a crack which poses a health and safety risk.

The inspection team also observed that the clinic’s grounds required attention. The

inspection team was informed that it does not have a groundsman. According to the nursing

staff, the grounds were only cleaned once by a service provider at the beginning of the 2013

year. However, the clinic was not provided any reasons why the service provider did to visit

the clinic.

Picture 7: The Brentpark clinic need proper gardening.



Lack of space: Brentpark clinic does not have enough space. The inspection team

observed that the sluice room was being used to store wheelchairs and other essentials. A

concern of lack of confidentiality during consultation was also raised by the nursing staff. For

instance, it was indicated that the nurses often had to whisper to patients when dispensing

medication to protect their privacy due to the insufficient space.

Picture 8: Cluttered sluice room used to store wheelchairs and other essentials.

Furthermore, the staff did not have a proper kitchen and was using the store room for

medicines as kitchen.

Picture 9: A store room for medicines is also used to keep food for staff.



Lack of water: Another challenge at Brentpark clinic related to poor water supply from the

Moqhaka Local Municipality. Although the inspection team was shown a water tank which

was donated to the clinic by the Municipality, it had not been installed. The lack of water

poses a serious hygiene challenge.

Picture 10: The water tank at Brentpark clinic which needs to be installed.

At Bophelong clinic the nursing staff complained about the quality of water which led to a

number of cases of diarrhoea.



6.2 Access to information

The Batho Pele principle of access to information requires information to be readily available

to citizens in order to empower them and address their needs.

Service charters: The inspection team found that service charters and other key

information were displayed in all facilities visited, and these were displayed in English,

Afrikaans and Sesotho. Sesotho is one of the predominantly spoken languages in the areas

visited, which was empowering and restored the dignity of the previously disadvantaged

communities. It was also in line with the Batho Pele principle of Information.

Picture 11: Poster in Sesotho and depicting tips on how to wash hands to promote hygiene.



Business hours: All the inspected facilities had clearly displayed their business hours as

required by Batho Pele principle of access.

Picture 12: Business hours displayed at Brentpark Clinic.

Redress: In order to elicit feedback from citizens on the services they received, all national

and provincial departments were expected to have complaint/suggestion boxes. The

inspection team found that there were complaint/suggestion boxes in all hospitals and clinics

visited. The complaint procedure was displayed next to the complaint/suggestion boxes and

it was written in English and Sesotho. It was also found at Tokollo hospital that there was a

quality assurance coordinator responsible for opening the box and ensuring that complaints

were resolved at the lowest possible level.

6.3 Talking to citizens

Citizens as consumers of the services provided by the institutions are in the best position to

give feedback on the state of service delivery. Their views and comments are important in

any effort meant to improve service delivery. Interviews were conducted with randomly

selected citizens on the quality of services rendered.

Availability of medicines and equipment: Most citizens at the visited hospitals and the

clinics indicated that they promptly received their medication after consultation. They also

stated that the facilities had sufficient equipment to provide quality services to them.

However, one citizen at Bophelong clinic informed the inspection team that there were

previously instances where patients were turned away and requested to return on specific

days due to unavailability of medication. The aforementioned concern was consistent with

the findings at the Provincial Office relating to non-payment of suppliers which affected the

supply to the Medical Depot at the beginning of the 2013/14 financial year. The inspection

team also observed that the clinic did not have carry bags for dispensing medication, which

exposed the patients’ medication to other people and, therefore, infringed on their



constitutional right to privacy. The views of the interviewed citizens corroborated the

responses of the nursing staff that there were few challenges with the availability of

medicines and quality of medical equipment.

Confidentiality: The inspection team was informed by citizens at Brentpark clinic that there

was lack of confidentiality with regard to patients’ medical files based on the filing system

used by the clinic. It was observed that the clinic has labelled files for HIV/AIDS with a blue

sticker. According to the interviewed citizens this information was known to other patients

and as such, infringed on the right to privacy of the affected patients who did not wish to

disclose their medical condition. The leaking of information about the health of patients is in

contravention of the provisions of the NHA which states that “all information concerning a

user, including information relating to his or her health status, treatment or stay in a health

establishment is confidential”17.

Waiting time: Interviewed patients in most of the facilities visited informed the inspection

team that they waited too long before they were attended to. Most citizens mentioned that

the waiting period was on average 3 hours, except for Tokollo hospital where citizens

indicated the waiting period as approximately 1 hour. It should, however, be mentioned that

the staff at the visited facilities informed the inspection team that waiting times varied on

average from 15 minutes to four (4) hours depending on the nature of the case being dealt

with.

Access: Although it was found that in most cases clinics were located within a radius of 5

kilometres (km) from residential areas as required by the norms and standards for health

clinics, there were instances such as in Phuthaditjhaba where citizens travelled between

10km to 20km to access a clinic. Citizens were concerned that the distances were too far to

the extent that they had to utilize public transport which was costly, especially to the poor

and vulnerable.

Consultation: During interaction with citizens in all visited clinics, the inspection team was

informed that there were clinic committees which provided them an opportunity to raise their

concerns with the clinic management to ensure improved quality of services. This finding is

in line with Batho Pele principle of consultation. It is also consistent with the observation

made by the inspection team with regard to redress above.

It is the view of the PSC that the concerns of the patients with regard to the waiting time

suggest that the standards were not consulted with them to ensure that they were clearly

understood and their buy-in obtained. The Batho Pele principles of consultation and

information require public institutions to adequately consult with citizens and provide them

with sufficient information in order to empower them in providing inputs on the quality of

services they receive.

17 Republic of South Africa. National Department of Health. The National Health Act. 2003.



7. IMPLEMENTATION OF PSC RECOMMENDATIONS

The inspection team followed up on the PSC’s previous recommendations emanating from

the inspections of primary health care facilities conducted in 200918. Overall, the findings

have shown that 16 (94%) of the 17 recommendations were implemented by the FSDoH.

Only the recommendation relating to the erection of ramps at Thabo Mofutsanyana remained

to be implemented. The District Office indicated that the matter had been referred to the

provincial Department of Public Works as the responsible institution for the refurbishing of

state properties. The high percentage of implementation of the PSC’s recommendations by

the FSDoH 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

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 the 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;

Human resource planning, development and management; and

Information management and systems support.

An 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 commitment

by the FSDoH in addressing the identified staff shortage especially of professional nurses

and doctors. The RX Solution (information management system) plays a key role in the

management of availability of medicines, and its roll-out to all health facilities is paramount.

Apart from the few challenges that have been identified during the inspections, it can be

inferred that the facilities are ready for the implementation of the NHI.

18 Republic of South Africa. Consolidated Report on Inspections of Primary Health Care Delivery Sites: Department of

Health. 2010.



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 FSDoH should collaborate with the Departments of Higher Education and

Training, Public Works and Human Settlements to devise a strategy for the

recruitment and retention of doctors, nursing professionals and pharmacists. It follows,

therefore, that the imminent review of the organisational structures of facilities by the

MEC should incorporate inputs relating to availability of accommodation and

amenities. (A plan of action should be put in place by June 2015).

The FSDoH should strengthen its monitoring system of suppliers of equipment to

ensure that suppliers of poor quality equipment were identified and blacklisted in order

to exclude them from future procurement processes. A plan of action to be in place by

June 2015.

The FSDoH should put a system in place which is linked to performance management

to ensure that that District Offices visit health facilities, especially clinics, monthly as

required by the Handbook for Clinic/CHC Managers. This should be implemented by

October 2014

The FSDoH should immediately ensure that suppliers are paid on time as required by

the Treasury regulations to ensure availability of medicines at the Medical Depot and

facilities. Feedback in this regard should be provided to the PSC by October 2014.

Training should be provided to the staff in the necessary protocols of dispensing

medication especially in the management of adverse drug events. A training

programme should be in place by October 2014.

Computers and network points should be provided at all facilities. Provision in the

budget should be made this regard. This should include the procurement of new X-

Ray equipment for Tokollo hospital as well as the roll out of the RX Solution to all

clinics. (In this regard, a plan of action should be put in place by December 2014).

The FSDoH should address the concerns of waiting time through consultation

processes in line with Batho Pele (In this regard, a plan of action to be in place by

December 2014).

9.2 Unannounced Inspections

The refurbishing of Brentpark and Bophelong clinics should be undertaken to address

the challenge of lack of space (at Brentpark) and the identified crack (at Bophelong).

(In this regard, a plan of action should be put in place by April 2015).



Elizabeth Ross hospital should be provided with an emergency generator to ensure

that the hospital’s functions are not disrupted when there is power failure. This should

be done immediately.

Brentpark clinic’s filing system needs should be reviewed to ensure confidentiality of

information on patients in line with the NHA. This should be done by 31 March 2015.

The FSDoH should engage the Moqhaka Local Municipality in order to address the

challenge of water supply experienced by Brentpark and Bophelong clinics. In

addition, the Department should approach the Maluti-A-Phofung Local Municipality to

find a solution to the frequent power disruptions affecting hospitals and clinics in the

area. This should be done immediately. Feedback in this regard should be provided to

the PSC by October 2014.

10. CONCLUSION

The findings of the inspections have shown that there are few challenges of availability of

medicines and medical equipment at the visited sites. Key challenges identified related to

budgetary constraints impeding the roll out of the RX Solution to all clinics, general staff

shortage of professionals, water supply in the Moqhaka Local Municipality where Brentpark

and Bophelong clinics are located, as well as frequent power failures affecting Elizabeth

Ross hospital. It is hoped that the recommendations will assist the FSDoH 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.

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:

Free State Province 28

ANNEXURE A: A LIST OF FACILITIES VISITED AND OFFICIALS THAT WERE ENGAGED

Name of Institution Date Names and designation of interviewed personnel Inspection Team Members

Fezile Dabi District Office 30.09.13 Ms M Mokotso; Acting Manager

Mr MSG Shuping: Deputy Manager

Mr VS Malatse; PHC Manager

Mr TE Taje: Assistant Director: SCM

Mr Matela Mohale

Mr Martin Chale

Ms Mmapeu De Jenga

Ms Ntshebo Adoro

Ms Lindi Qithi

Ms Tshiamo Mothibi

Brentpark Clinic 30.09.13 Sr RIB Bouwer: Operational Manager

PM Motete: Pharmacy Assistant

Bophelong Clinic 30.09.13 Sr MO Mosala: Operational Manager

KD Beukes: Pharmacy Assistant

Tokollo Hospital 01.10.13 MA Makhalema: Head Administration

JJ Fourie: Senior Artisan Foreman

SR Sithole: Senior Supply Chain Practitioner

R Motebele: Assistant Manager Nursing

PA Makoti: Senior Admin Officer

MP Jansen: Infection Control and OHP

PM Tshabalala: Quality Assurance Coordinator

MR Tlopo: Quality Assurance Coordinator

RS Mokoena: Chief Medical Officer

TD Tsotetsi: HR & Employment Relations Officer

PS Lesibo: Mafube/Tokollo Board Member

DS Letsele: OPM Maternity

MV Ratshitanga: Artisan

M Matseliso: Head Nursing

MJH Wilbach: Pharmacist Tokollo

S Mofumane: OPM: G/W, CAS, Theatre

SR Noge: Chief Executive Officer

Thabo Mofutsanyana

Health District

07.10.2013 L Schabort: District Pharmacist

DS Ntsutle: Senior Manager

FC Moloi: Chief Executive Officer

MC Ramokotjo: Manager - District Health Clinics

Mr Matela Mohale

Ms Ntshebo Adoro

Ms Lindi Qithi

Ms Tshiamo Mothibi

Elizabeth Ross District 08.10.2013 MB Moloi: Senior Admin Officer – Supply Chain Management



Name of Institution Date Names and designation of interviewed personnel Inspection Team Members

Hospital MS Mohale: Senior Admin Officer – Finance

M Mlangeni: HCTNX Coordinator

PP Tsatsa: Pharmacist

MC Lerole: Acting Chief Executive Officer

Phuthaditjhaba Clinic 08.10.2013 M Motloung: DOH

J Mahlasela: MAP Primary Health Care Coordinator

BM Kwahela: Operational Manager

Bluegumbosch Clinic 09.10.2013 L Matsaba: Operational Manager

M Motloung: DOH

J Mahlasela: MAP Primary Health Care Coordinator

Medical Depot 29.10.2013 Ms C Claasens: Assistant Manager: SCM

MS M Smits: Pharmacist – Procurement

Ms N Phitsane: Chief Director – SCM

Ms S Mthethwa: Assistant Manager – Finance

Mr K Kgomo: Manager – Pharmaceutical

Ms K Mosikare – Manager –Medpharm



ANNEXURE B1: ANNOUNCED INSPECTIONS IN THE CLINICS:

Availability of medical equipment at inspected clinics

√ Norms and standards adhered to

X Norms and standards not adhered to

Me

dic

al e

qu

ipm

en

t

Brent Park 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

√ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

Bophelong Clinic

√ x √ √ √ √ x x √ √ √ √ √ √ √ √ x

Blood pressure machines: Gets overheated after prolonged usage then produce incorrect readings.

Haemoglobinometer: Bophelong clinic had two Haemoglobinometers, one hand-held but deemed to be mostly unreliable by the nursing

staff, and the other which required glass plates for use and found to be in short supply.

Glucometer: Glucometer was in short supply in that the clinic had one such equipment used by all the nursing staff.

Furthermore, batteries for the equipment were in short supply to the extent that the nursing personnel were forced

to recharge the used batteries by placing them in the sun on the window sills.

Condom dispenser: Although the condom dispenser was available and appropriately placed where the citizens could easily access it,

there were, however, no condoms provided in the dispenser.



ANNEXURE B1: Availability of medical equipment at inspected clinics

Me

dic

al e

qu

ipm

en

t Phuthaditjhaba 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 √ √ √ √ √ √ √

The clinic has a landline telephone only. A two-way radio is required as indicated by the Head of clinic for usage as backup.

Bluegumbosch Clinic

√ √ √ √ √ √ √ √ √ x √ √ √ √ √ √ √

The clinic has a landline telephone only. A two-way radio is required as indicated by the Head of clinic for usage as backup.



ANNEXURE B2: Availability of medical equipment at the inspected hospitals

Tokollo District Hospital

Me

dic

al 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

Ha

em

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

ct

no

rma

l d

eliv

erie

s

EC

G

Em

erg

en

cy e

qu

ipm

en

t fo

r

tra

um

a a

nd

em

erg

ency

Tro

lleys w

ith

em

erg

ency

dru

gs &

re

suscita

tion

eq

uip

me

nt

√ √ √ √ √ √ √ √ √ x √ √ √ √ √ √ √ √ √ √

General X-ray room: Although the X-ray equipment was found to be working, the hospital was concerned that it had almost reached the end

of its lifespan and, therefore, needed to be replaced.

Elizabeth Ross District Hospital

√ √ √ √ √ √ √ √ √ x x x √ √ √ √ √ √ √ √

General X-ray room: X-ray machine was not functioning due to unavailability of a central processing unit (CPU) that was allegedly stolen on

25/09/13. The matter was still under investigation as informed by management during inspection. Patients were referred

to a nearby hospital, namely Manapo Regional Hospital.

Snellen chart: The hospital did not have an eye care professional.

Veno-Puncher set: Two (2) towel packs were used as an alternative.



ANNEXURE C1: Availability of medicines at inspected clinics



Brent Park 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

√ √ √ √ √

Bophelong Clinic

√ √ √ √ x*

* Although most medicines were found to be available at the clinic, concerns of serious shortage of Pentaxim (i.e. vaccination for 2 to 4

months old babies) and Ferrous Sulphate (used for boosting the haemoglobin level in pregnant mothers) were raised by the nursing

staff. Seriously disconcerting were reports that Ferrous Sulphate was not available despite an order having been placed with the District

Office for over two months.



ANNEXURE C1: Availability of medicines at inspected clinics

Phuthaditjhaba 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

√ √ √ √ √

* Spare globes were not available – the clinic was awaiting delivery of ordered stock, which included globes as informed during the

inspection

Bluegumbosch Clinic

√ √ √ √ √



ANNEXURE C2: Availability of medicines at inspected hospitals



Tokollo District Hospital

Me

dic

ine

s

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

√ √ √ √ √

Elizabeth Ross District Hospital

√ √ √ √ √



ANNEXURE D: THE STATUS ON THE IMPLEMENTATION OF RECOMMENDATIONS OF THE PSC’S INSPECTIONS CONDUCTED IN

2009

Details of the clinic Recommendations Implemented Not implemented

Thabo

Mofutsanyana

District Office

Ramps for people with disabilities should be

erected. In this regard a plan of action should be

in place by April 2010.

No Not yet implemented

(District lack capacity; the

matter to be referred to the

Department of Public works)

Procurement processes should be improved as

this impact negatively on the functioning of clinics.

In this regard, a plan of action should be in place

by April 2010.

Yes

Should have vehicles available to visit clinics. In

this regard, a plan of action should be in place by

April 2010.

Yes

Phuthaditjhaba

Clinic

Should display outside and inside signage at their

buildings by April 2010.

Yes

Should renovate buildings. In this regard a plan

of action should be put in place by April 2010.

Partially

(Renovation of the clinic

was done partially, only the

waiting area and the

corridor were painted but

not the consulting rooms)

Clinics should be provided with medical

equipment and medication

Yes

Vacant posts are to be filled to address staff

shortage at the clinics. In this regard a plan of

action should be in place by April 2010. The clinic

manager should ensure that all service users who

Yes




are in the queues are attended to instead of being

sent home because it is knock off time. This

should be done immediately.

Service Charters should be translated into the

languages spoken within the jurisdiction of clinic

and not just English. In this regard a plan of

action should be put in place by April 2010.

Yes

Staff should be provided with name tags by April

2010 and must wear them.

Yes

Bluegumbosch

Clinic

Should display outside and inside signage at their

buildings by April 2010.

Yes

Clinics should be provided with medical

equipment and medication immediately

Yes

Vacant posts are to be filled to address staff

shortage at the clinics. In this regard a plan of

action should be in place by April 2010.

Queue Marshall appointed

and reallocation of nurses

done in line with workload.

Clinic manager should immediately ensure that all

service users who are in the queues are attended

to instead of being sent home because it was

knock-off time.

No patients are returned

unattended and there is a

Free State circular in this

regard against returning

patients unattended.

Reception area and help desk should be clearly

identified.

Yes

A staff member should be assigned to guide and

direct citizens upon arrival. In this regard a plan of

action should be put in place by April 2010.

Queue Marshalls

appointed.

Service Charters should be translated into the Yes




languages spoken within the jurisdiction of clinic

and not just English. In this regard a plan of action

should be put in place by April 2010.

Staff should be provided with name tags by April

2010 and must wear them.

Yes

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