PRESS
STATEMENT
HEALTH SERVICES IN THE EASTERN CAPE
19
SEPTEMBER 2013
Good Morning!
Last week the Eastern Cape Health
Coalition brought to the attention of the media and the public, a lot of
problems pertaining to the healthcare system in the Eastern Cape. In fact the
document that defines the problem is poignantly entitled “Death and Dying in
the Eastern Cape – an investigation into the collapse of the healthcare system”
I am not here today to challenge and
contest whether this is true or not. I am rather here to confirm that both the
Department of Health and the National Treasury have been aware of some of these
allegations for sometime. And I want to assure the public that we have not been
resting on our laurels. The fact that we have not yet implemented some of the
mooted solutions is simply because the problems needed thorough understanding
through deep investigation and diagnosis of the problems and application of
appropriate and ever-lasting solution, not stop-gap measures as some people
usually demand.
Though it did take sometime, we have
luckily arrived at the situation where at this time when the Coalition is
raising these issues publicly, we are also ready to announce some of the
measures which we have learnt and planned over a period of time.
The summary of the issues raised by the
Coalition are in page 3 of their document, entitled “Fix the Eastern Cape
Health System” (scan document page 3)
To be systematic, I have arranged this
presentation into four (4) sections, namely:
·
Section A: Infrastructure
·
Section B: The Report of the Investigation
team
·
Section C: Drug Supply and Strategies to
improve hospital performance
·
Section D: Procurement Reform
As I have said earlier, both National
Health and National Treasury have been aware of the major health, financial and
resource problems in the Eastern Cape Healthcare system in general, and OR
Tambo District in particular.
Not surprising then, that 90% of this
document titled “Death and Dying ….” is about the OR Tambo District. We have
also arrived at the same conclusion.
SECTION
A
- Infrastructure
You are aware that we have selected
eleven (11) Districts for the piloting of NHI. One of these Districts, which we
chose deliberately, was OR Tambo District. We chose it as a Pilot specifically
because we wanted to take that opportunity to fix a multiplicity of problems
the District is experiencing. Let me deviate a bit just to remind you what we
said we would do in the Pilot Districts. We selected five (5) areas, viz:
-
Infrastructure
-
Human Resources (HR)
-
Quality of Healthcare as determined by the
Six (6) basic standards of Cleanliness, Drug Stock-outs, Infection Control,
Attitude of Staff to patients, Waiting times, Safety and Security of staff and
patients.
-
Re-engineering
of Primary Health Care (PHC) and lastly
-
Contracting of GPs into public clinics.
We then decided that all the other four
areas to be piloted will largely depend on proper execution of the first one
that is appropriate infrastructure. We note the similarities between what we
decided and what the Coalition has arrived at. We described it as
Infrastructure and they defined it in their document as Facilities, whereby it
is stated: “the poor quality of many facilities hampers the delivery of healthcare.
They often lack electricity and running water. Many are too small for the
number of people served, and some are literally falling apart”.
We have started 18 months ago to look
exactly into this problem, after we received the facility audit report of all
the 4 200 health facilities in the country conducted in 2010/2011.
In responding to the audit results, we
decided to tackle the NHI pilot districts first. In this regard we sent in a group of
Engineers from the DBSA, CSIR, and the National Department of Health to these
areas. We call these teams Built Environment Experts. Over and above Geo-referencing
all these facilities, their geographic information was captured and their
conditions evaluated in terms of their infrastructure services status covering
the following fields:
·
Infrastructure
Support Services
o
Percentage
of site development
o
External
water supply conditions
o
External
electrical supply conditions
o
Sewerage
conditions
o
Waste
disposal conditions
o
Number
of toilets
·
Buildings
o
External
walls conditions
o
Ceiling
conditions
o
Electrical
conditions
o
Plumbing
conditions of toilets and basins
o
Internal
water supply conditions
o
Internal
walls conditions
o
Roof
material conditions
o
Floor
materials conditions
·
Space sufficiency
o
Waiting
areas
o
Service
areas
·
Distance
o
Total
catchment population
o
Population
more than 5 Km from the facility
o
Weighted
population more than 5 Km distance from the facility
I think it is important for me to show
you the result of the work that took place over that 18 month period to date. I
will just choose 4 of the pilot districts that were the most hard-hit in terms
of infrastructure problems due to the fact that they reside within the former
Bantustans. The following key was used to evaluate them:
And here are the results (Slide show)
You do not have to be one of these Built
Experts to notice the massive infrastructural backlog in terms of both space
and quality that the OR Tambo District is experiencing.
As you can see the key to the
infrastructure evaluation is colour coded.
It might be important for me to interprete the meaning of the colours.
Red means total replacement because it has gone beyond the state of any renovations.
i.e if the roof is red it means it must be totally replaced, if it is the walls
that are red, it means the walls must be replaced. If on the other hand it is the whole building
that is red, it means it is the whole building that must be demolished and be
started afresh.
Amber means major refurbishment, and
Green means minor maintenance.
I am sure you have noticed that most of
the OR Tambo is Red in terms of the state of the buildings, electricity supply,
water supply and overall space availability.
The profile of OR Tambo District is as
follows: 197 health facilities, covering 167 clinics, 12 Community Health
Centres (CHCs), 13 District Hospitals, 2 Regional Hospitals, and 3 Specialised Hospitals.
Using the criteria as mentioned above,
the score in the OR Tambo District is as follows:
(i)
8 clinics need to be completely demolished
and will be rebuilt from scratch, and 5 of them will be built in this very
financial year. Contractors will be on site by January 2014 and the contract
period will be 8 months (layout plan);
(ii)
2 hospitals (need to be completely demolished
and will be rebuilt from scratch. The appointment of professional service
providers will be finalized – 1 in December 2013 (Bambisana Hospital) and in
January 2014 (Zithulele Hospital), while the contractors will be on site for
Bambisana and Zithulele Hospitals in May 2014 and June 2014 respectively.
The duration of the contract
will be 36 months. For St. Barnabas
Hospital the whole psychiatric section will undergo major refurbishment.
(iii)
30 clinics have a got a problem of space for
the size of their populations. There are varying numbers of problems of water
and electricity in this category. There is an urgent need for this additional space
for doctors’ consulting rooms and patients’ waiting areas as well as toilets. Hence
scientifically designed and manufactured Park Homes with technical and
manufacturing specifications prepared by CSIR to minimize the operational cost
of building in the areas of, thermo properties to avoid mechanical air conditioning
thus saving on energy, durability and fitness for clinical purpose with minimum
lifespan of 20 years will be installed. Installation has already been completed
in 4 of them, and we hope the rest will be completed by the end of the year or
early next year. This 20 year period will give us a chance to plan properly without
being under pressure. I need to explain
that the parkhomes won’t just come naked, if there is a municipal water source
in that area then the installers have to connect at the time of
installation. If there is none the will
have to put up a bore hole immediately.
If there is an electricity grid they will
connect but if there is none the parkhome will have to be installed with a
generator. If there is sewerage system
it will be connected, if there is none then the septic tank will have to be
installed. In other words all this are
the specifications of the parkhome depending on the population as small as they
two consulting rooms, the medium four consulting rooms and the biggest six
consulting rooms.
(iv)
2 Nursing Colleges will be refurbished to
full functionality. These are Butterworth Nursing College and Madzine-Ka-Zulu
Nursing College. The contractors will be on site by October 2013 and the
completion date is envisaged to be March 2014.
(v)
As you saw from the slides that show Red for
total replacement, Amber for major rehabilitation and Green for minor
maintenance, the costing work of what is indicated on the slides is being done
and will be completed for all the NHI pilot districts by November 2014, but for
OR Tambo because it is being given top priority, the costing will have been
completed by the end of this year so that we can start appointing contractors.
(vi)
We are working around the clock with the
Provincial Department of Health to improve infrastructure in the rest of the
province. In this case we are implementing 287 projects covering new additions,
upgrade, renovation and maintenance works in 132 facilities. 159 of these projects
are at construction phase while the rest are at developmental phase. These
facilities cover 106 PHC facilities, 8 Nursing Colleges, while the others are
hospitals. The total amount of R1.045 billion has been budgeted for this work
up to the end of the financial year.
SECTION
B:
The Report of the Investigation team
Last week on hearing of the complaints,
some of whom sounded urgent, I quickly dispatched an investigation team consisting
of people experienced in hospital management, procurement systems, infrastructure,
maternal and child health, as well as representatives from the Eastern Cape
Provincial Health Department.
The
purpose of the visit
1. To
investigate the state of affairs in Holy
Cross Hospital following allegations from a report written by a suspended
doctor, Dr Dingeman Rijken, who was an employee of the hospital
2. Find
facts on allegations on state of health services in the Eastern Cape as stated
in the document by the coalition titled:’ Death and Dying in the Eastern Cape’
,an investigation into the collapse of a health system
3. 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
Findings from interviews
with Nurses, midwives and visits to Maternity Wards:
Five nurses/ midwives
were interviewed; all worked in the hospital on rotation basis in
different units and had clear knowledge of the situation in the hospital. Most
have been working at the hospital for more than 10 years.
1.
Staffing: maternity
·
8 Advanced midwives, one working as area
manger
·
9 Midwives
·
5 Enrolled nurses
·
3 Enrolled Nursing Assistants
2.
Essential equipment for maternity ward
·
There are no basic equipment to use for
patient care
·
No Blood Pressure(BP) machines (Midwives
contributed R17 each from own pockets and procured 1 Baumonometer / BP machines)
·
No fetal heart monitors (Three midwives has
each their own feto scopes)
·
Few thermometers
·
No Glucometer
·
No baby warmers on the resuscitators with
babies being resuscitated in cold rooms as there are no heaters
·
A lot of linen, green towels, gowns and
sheets were used to cover chairs in the ward
4. Quality
of care
·
Most nurses interviewed believed that they
are trying hard to provide optimal care to the patients but said there is no
team work in the facility
·
All admitted that there are some practices by
some colleagues that may contribute to sub optimal care
·
They are aware of some instances where charting
of the vital signs, medicines and the partogram are recorded even though not
executed
·
Most deliveries have records done after
delivery
5. Attitude
of staff
·
All nurses interviewed acknowledged that
staff attitude towards patients, relatives and even amongst themselves in the
facility is not acceptable
·
The general feeling was that management had
no power over the unacceptable behaviour as they are friends with the wrong
doers
·
They feel that there is generally no
leadership and guidance, as such, everyone does as they like
·
There are employees who are dedicated to
their work but are discouraged by the actions of other e.g. Nurses will go for
tea at their residence and take long to come back or some will sit in the duty
room for hours having lunch.
6. Leadership and management
·
The facility lacks quality leadership and
management
·
There is a potential for the facility to be
the best in the district or EC should there be good management.
It
should be noted that this hospital was part of the Hospital Revitalisation
Programme and a sum of R105 million has been spent to refurbish this hospital,
the work was completed in January 2012.
·
No records of meetings, in service education
or MMR/PMR including near misses meetings held
·
Nurses and midwives not made aware of crucial
policies, guidelines and targets and other directives that should be guiding
their day to day practice. The 10 point plan, MDGs, Mission, Vision, Brand
value were however, printed and pasted on the walls in the admin offices.
7. Purchase of folders
Folders that could be
purchased for R3000.00 have been found to have been purchased for
R30 000.00, which means it was 10 times what it ought to cost.
8. Recommendations
·
In line with the recommendations of the team,
it is my intention that 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.
·
Again in line with the recommendations of the
team, it is my intention that the Nursing Services Manager should also 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.
·
In line with the recommendations of the team,
it is my intention that progressive disciplinary measures should be instituted
against the Hospital Administrator.
·
As both the CEO and the Nursing Service
Manager are nurses by profession, it is my intention that they be reported to
the South African Nursing Council (SANC) for breach of professional ethics.
·
An urgent forensic audit to be done in this
hospital in as far as the purchase of hospital files is concerned.
·
As far as the District Management is
concerned, the Deputy Minister of Health, Dr Gwen Ramokgopa visited the OR
Tambo District in May this year. In interacting with the District Management,
she concluded that the management of that District is grossly inadequate and
recommended that the Province do something about it. When the Province started
to take action in accordance with the Deputy Minister’s recommendation, the
District Manager resigned. The province is in the process of interviewing for a
new District Manager and will advise that this be expedited.
·
It will not be fair for me to take only
action in order for people to take accountability without attempting to help
the patients who use these facilities. Hence the following equipment have been
purchased by the National Department of Health and dispatched to Holy Cross
Hospital:
-Baumanometers x20
-Neonatal Ambubags x10
-Paediatric Ambubags x10
-Adult Ambubags x10
-Pulse Oxymeters x10
-Electric POP saw x2
-Infusion pumps x8
-Patient body warmers x5
-Vacuum extraction x2
-Disposable thermometers
x5000 in boxes
-Suction machines x10
-Glucometers x5
-Foetoscopes x10
-ENT sets x5
-Laryngoscopes
·
Gloves, syringes, needles in various size
These equipment has
been dispatched yesterday.
There
was no time for the team to visit the other hospitals in the District, but to
err on the side of caution, we believe they have got similar needs. And hence
the equipment listed above will be purchased and dispatched to all other 13
District Hospitals, 2 Regional Hospitals and 3 Specialised Hospitals as from
next week.
Other
equipment for Eastern Cape
According to information at our
disposal, as of August 2013 the Eastern Cape has a backlog of 2 581 wheelchairs,
and other assistive devices like hearing aids (703), prosthesis (707), cochler
implants (2). These will cost a total of R15.3 million and it is our intention
that the National Department of Health will purchase them and dispatch them in
the next coming weeks.
Ambulances
Apart from shortages of ambulances in
most of the Eastern Cape, the OR Tambo is once more the hardest hit and the
rough terrain makes it even worse. Fortunately the Province has already been
aware of this and a total of 100 ambulances have already been ordered and are
busy been converted and we wish to thank the province for 26 of them will be
dispatched to OR Tambo District as soon as the conversion has been completed.
Section
C: Drug Supply and Strategies to improve hospital performance
A few weeks ago you were invited here to
a press conference to announce a Development Accord signed between the National
Department of Health, the Gauteng Provincial Department of Health and the
University of the Witwatersrand under the Vice-Chancellor. This Accord was
aimed at improving hospital management, increase quality of care, ensure
constant drug supply, minimize the shortage of equipment and other consumables.
Due to lack of time, I would not want to repeat the Accord here but just to
remind you in summary, it deals with:
(a)
Increasing delegations of CEOs
(b)
Allocation of contingency budget to CEOs
(c)
Direct procurement and delivery from
suppliers to hospitals
(d)
Establish management structures to monitor
and manage the process to ensure continuous availability of non-negotiables
items
-
Vetting committee
-
Medicine and Therapeutic Committee
-
Clinical Department meetings
-
Hospital Executive Management meetings
-
Ward Management
(e)
Improving supply chain management/procurement
processes
-
Develop a profile of all the essential needs
of all the wards
-
Develop a minimum and maximum stock level in
the stores for these items, monitors the stock levels in these items on a daily
basis, place orders for the items in advance on a rolling 3 month basis
(f)
Improved management of essential equipment
-
Equipment Committee:
(i)
In this new process, we will wish to order
equipment from reputable suppliers which will come with a proper maintenance
plan;
(ii)
Essential equipment list should be developed
by all hospitals. This Essential equipment list should be categorized according
to level of care, i.e Central Hospital, Regional Hospital and District Hospital
After the above Accord was signed with
Gauteng for hospitals falling under the following categories:
·
All Central Hospitals;
·
All Tertiary Hospitals;
·
All Regional Hospitals; and
·
Strategic District Hospitals
In the case of Gauteng, this will cover
20 hospitals.
In July this year, at the National
Health Council, each province was asked to give the number of hospitals falling
within these categories. Eastern Cape provided us with 16 hospitals.
Progress
thus far:
The DDG: Hospital Services and HR, was
tasked with the job of visiting all provinces, meet the provincial and district
management as well as the CEOs of these particular hospitals, to outline this
plan to them.
On 22 August 2013 such a meeting took
place in the Eastern Cape. We will ask the DDG to follow up so that the
formation of the Committees as mentioned above will be completed by the end of
September.
Section
D: Procurement Reform
In 2011 the Minister of Finance, being
worried by the problem of Supply Chain Management in some provinces including
the Eastern Cape, formed a Multi-Agency team consisting of SARS, SIU,
Accountant General, and National Treasury. This team spent a long time in the
Eastern Cape to establish problems, their origin, and possible solutions, in
order to intervene on supply chain issues. Their work has been completed and
cases in which fraud, corruption, and other misdemeanors were found, have been
referred to the investigative agencies.
Early this year, the Minister of Finance
established the Office of the Chief Procurement Officer (CPO). Procurement
Transformation Initiative (PTI) has been established to develop procurement
operations end to end.
In agreement with the Minister of
Finance, this PTI will be urgently implemented within the Provincial Department
of Health in the Eastern Cape, Gauteng and Limpopo. It is our intention that
teams will be dispatched very soon especially to the Eastern Cape to start with
implementation process.
The European Union (EU) has donated R40
million to assist with the implementation of this initiative.
The Memorandum of understanding has
already been signed between Chief Procurement Officer in National Treasury and
the Director General of the Department of Health to facilitate the
implementation of the procurement reform in the Eastern Cape, Gauteng and
Limpopo provincial health departments.
In conclusion, I wish to state that the
work of rebuilding the Department of Health in the Eastern Cape has been going
on for some time. In May 2013 I and the
Deputy Minister spent four hours with the Executive Council in Bisho. Two weeks
ago a new HOD has been appointed; he was working here at the head office with
us. After along time of Acting position
the Eastern Cape has got a permanent CFO and a permanent DDG for Human
Resources. It is important to mention
this because this where the special positions where serious weaknesses were
observed in the past. I have just spoken
to the new HOD this week to prioritise appropriate appointment in the
directorate of Pharmaceutical services.
Lastly, the Eastern Cape regrettably
delayed the appointment of the CEOs which have been going on in other provinces
since last year. But I am happy to
announce that the adverts for the new CEO positions in a number of hospitals
are out and will start appearing in the media in the next few days.
I
thank you
