Department of Health 2019/20 Annual Report

Meeting report

The Chairperson welcomed all present in the meeting, and said the Committee would be deliberating on the annual report of the Department of Health for the 2019/20 financial year. She asked the Minister to provide a brief review and some remarks on the report.

Minister's overview

Dr Nomafrench Mbombo, Western Cape Minister of Health, said it should be noted that it was a pre-COVID-19 report from 2019. This was part of the strategic plan for the 2030 Western Cape trial, the first part of which would end in 2024. This was also an election year, and some were not sure if they would return after elections. A lot of infrastructure had been planned at the time, and the Department of Health (DoH) wanted to ensure that it tackled some of the issues it was faced with. Its entire budget was spent on infrastructure. It had had a clean audit in the financial year for the second time.

The Department had ensured that it had a pilot for universal health coverage related to the National Health Insurance Bill. It had already collaborated inter-provincially with the Eastern Cape and KwaZulu-Natal (KZN). Meetings had been held between officials and Members of the Executive Councils (MECs).

She emphasised that the highlight of the year was about the Department receiving a clean audit and focusing on its infrastructure. The previous Head of Department's (HOD’s) term had also ended. There were actors, producers and stylists, and the people who worked behind the scenes, and they were present to answer any questions.

Tribute to outgoing HOD

Dr Keith Cloete, Head of Health in the Western Cape, said Dr Beth Engelbrecht was the outgoing HOD, and commended her for what she had done over a period of five years in bringing the organisation to where it currently was. They were all extremely proud of the organisation and proud to be associated with it.

He said Members would have noticed that it was very late in the year to have an annual report, which was due to the unusual circumstances. The Auditor General (AG) had been very clear on why it had delayed the tabling of the report. The delayed tabling meant the Department could now reflect on a year prior to the COVID-19 pandemic and the great successes achieved during 2019/20. He commended everyone at the DoH for their hard work in preparing the Department for the pandemic. He also paid tribute to the clean audit it had received, given the complexity of what it had presided over.

The Chairperson asked if Members had any questions on the overviews presented by Minister Mbombo and Dr Cloete. It was a public hearing, so members of the public were also welcome to pose questions.

Members would refer to the necessary pages of the report, and the presentation would not be flighted.

2019/20 Annual Report

Part A -- General Information (Pages 5-26)

The Chairperson asked if Members had any questions.

Members did not have any questions.

Part B -- Performance Information (Pages 29-101)

The Chairperson asked if Members had any questions.

Ms R Windvogel (ANC) referred to page 32. She asked for an update from the Department on the building of the GF Jooste Hospital. She referred to page 35 and asked if there was any consideration given to safety for the patients who wait outside the gates in the dark and cold, and how this could be factored in. On page 41, she congratulated the Department for its clean audit and encouraged officials to put measures in place to improve conditions in the health facilities. It was kind of pointless to have a clean audit when there were cases of patients sleeping on the floor, and to have over 500 cases of irregular expenditure.

The Chairperson asked if Ms Windvogel was referring to any specific case on page 41. She had made reference to one incident, and needed to clarify this so the Minister or HOD could respond.

She said she received reports from people about this. Her brother had reported some issues to her which was also why she always stressed issues involving temporary or contract workers. This was part of the life experience about which people send in complaints.

Minister Mbombo said the Jooste Hospital situation was part of the 2018 report and could be answered another time. Given the COVID-19 pandemic, many infrastructure issues had been delayed to meet the lockdown requirements. On the diversion of funding, some funds had been promised to the Jooste and Tygerberg hospitals, but it was difficult to respond to general questions.

Clean audits were just one part of what the Department was supposed to do, and it would not be going to the Standing Committee on Public Accounts (SCOPA) if it was not important. Taxpayers’ money must be spent accordingly, which was why auditing was essential. She referred to a pack of apples, where one of the apples in the pack may be rotten or not of good quality. There was no way an entire seven million people could be satisfied. There must be processes in place, as some people did not want to approach lawyers or go to court. The lowest amount of litigation had occurred in the Western Cape, in comparison to other provinces. What was crucial was to have a space where people could converse and find out what happened. Sometimes it was about people sitting in an uncomfortable chair, but would like to lie down -- pictures would then be taken and spread around. People should ask questions, so the Department could respond. If one considered the burden of disease and the health outcomes, one would find that the system excelled in child health, maternal health, communicable diseases and access to health services, for example.

There should be mobile clinics, as in some clinics where there no dental or eye care services one would find people needing such services on a monthly basis. There was always a gap where the DoH needed to improve. There were hotlines that people could report any complaints to. People would always have to wait outside, given that people want to be first in line. This was the case with the Department of Home Affairs as well. Regardless of the time slot people fell into -- for example, 08h00 to 10h00 -- everyone would want to come early in the morning. In some areas, the Department worked with the municipality, and where there were transport and pick up points. In some instances, people could be accommodated in churches or councillors' offices. For example, at the Nyanga Clinic, there was nothing more they could do, as the environment was not safe for anyone, given the gang fights. Services were always open, even though it was dangerous for healthcare workers.

Dr Cloete said the Klipfontein Regional Hospital was formally registered, and funds had been allocated to it. The projected timelines for completion would be reported to the Committee.

He agreed with Minister Mbombo’s sentiments on accountability, serving citizens' needs -- being compassionate to citizens in need was something the Department took seriously. When someone had to lie on a hospital floor, this was because of service pressures, but the DoH was working on this. He emphasised that the dignity of people was a big priority for the Department.

The Chairperson asked if there were any follow-up questions.

Ms Windvogel thanked the Minister and Dr Cloete for their responses on service and the dignity of people. She wanted to know how over 500 cases of irregular expenditure had occurred within the Department. What mechanisms were in place to improve the supply chain management (SCM)?

Minister Mbombo said the focus should be on relativism, and what the 500 cases were about. It should be taken into consideration that the Department had clean finances and clean human resource (HR) management. It should be noted how the AG worked. It talked about the thresholds, so the mere fact that there were 500 cases of irregular expenditure did not mean it had reached a particular threshold to have findings.

Dr Cloete said it should be taken into consideration how irregular expenditure was recorded, what was done with the irregular expenditure, and how it was processed and managed over more than one financial year. The AG looked at the materiality and the risk to the Department. There had been a very stringent process to work through irregular expenditure over a period of years to improve the services within the Department.

Mr R Allen (DA) said he appreciated the work done during the financial year and the clean audit. He referred to page 18, where no unauthorised, fruitless and wasteful expenditure had been incurred during the financial year. This year had played a role in the Department heading into the "new normal" and the COVID-19 pandemic. He wished to commend the Department for its hard work.

Part C -- Governance (Pages 103-116)

This section would be dealt with by SCOPA.

The Chairperson asked if Members had any questions.

Ms N Bakubaku-Vos (ANC) referred to page 106. She asked to what extent sexual harassment in the workplace was a significant risk in the Department, and what had been done to prevent this from happening. She asked if the Committee could receive a detailed report on the state of all facilities in the province and updates on renovations and refurbishments that had taken place between 2019 and 2020, and those which would take place between 2020 and 2022. Which hospitals were in a worrying state and what plans were in place to renovate them?

On page 107, regarding the cases opened on 31 March 2020, what progress had been made with the investigations, and what had been the nature of transgressions? On the cases closed in 2019/20, the Department should provide more details on the matters investigated and recommendations.

Minister Mbombo said this was a manifestation or microcosm of what was happening in society at large. People appointed came from the same society. If there was a dysfunctional society with perverts and abusers, there would be a similar pool of people in any institution. What was crucial were the processes put in place in the labour relations acts and disciplinary measures? In the back of the pages of the annual performance plan (APP), the stages and progress could be seen.

Dr Cloete said there was a very strict sexual harassment policy in the Department, which was geared toward detection, reporting and not harassing victims. There were immediate measures for disciplinary and precautionary suspension for investigation purposes. There was also a very strict policy on dismissal. There was a zero tolerance approach, and an employee wellness programme in the system. The rights of people were emphasised, and they were encouraged to come forward if they felt inappropriate behaviour had been directed toward them.

COVID-19 procurement was not included in the current report. During 2021, which was subject to the current audit engagements, there were two special audit reports by the AG, and nothing had been found wanting in the Western Cape on the clean audits. There had been a very clear process.

The Chairperson said she was ruling on the second question on renovations made to facilities. As a Committee, it was a resolution to the Department requesting the relevant information sought by Ms Bakubaku-Vos.

Ms Bakubaku-Vos referred to page 107, and asked how the Department had minimised conflicts of interest involving COVID-19 related expenditure, and whether any cases of irregularities had been identified.

Ms Windvogel referred to page 108, and asked if all facilities were compliant and which were not. On page 110, how did the figures compare to the previous financial year? Had they increased or decreased? In which area had irregular expenditure occurred, and what were the details of the products procured? On page 111, how was the Department going to minimize its over-reliance on seasonal workers? She said this was very personal to her, because she lost her brother, as there had not been enough staff to assist him. What was stopping the Department from employing permanent staff with the money used on seasonal workers? On page 116 -- procuring and preferential procurement policy -- a progress report should be given on this, and should perhaps be made a resolution. When would this be fully implemented, what had caused the delays and for how much longer would it be in progress?

The Chairperson said this would be made a resolution of the Committee.

Dr Cloete said contract workers were interns or medical doctors that were studying to become specialists, or they were registrars. There were a large number of workers who were appointed by contract, given the nature of what they did. Agency staff were also used to relieve service pressures or for people going on leave. This was separate from the current reporting period. There were three clear distinct processes.

Mr Simon Kaye, Chief Financial Officer and Head of Corporate Services, DoH, said fraud cases were reported through provincial forensic services, who investigated and reported back to the Department on actions that had been or should be taken. The Committee would be informed on this ongoing rolling register. What was active today may not have been active 18 months ago.

He referred to page 239 of the financial statements, which provided a detailed breakdown under Note 23 and Note 23.2, and indicated the reconciliation of expenditure and detailed information. There were a number of auditing techniques and tools that were available. For example, when one procured off the Central Supplier Database (CSD), the list of all the directors were included in the procurement details of the company. This was done for the entire country, and was where issues could be picked up. Where people were identified with a conflict of interest, a process was followed, and this was guided by circulars. Recoveries were assessed through fruitless and wasteful expenditure frameworks, should there be a necessity. Guidelines had been put out by the provincial Treasury, and an update would be provided on this. There had been some issues of a technical nature which were impacting the entire country on definitions, and who should issue certificates. This should be resolved nationally, and was not a provincial issue.

Dr Laura Angeletti du Toit, Chief Director: Facilities and Infrastructure Management, said each facility was required every year to have an inspection from the relevant municipal fire officer, who had to visit the facility and issue a certificate of compliance. The compliance certificate should be issued annually. Some facilities having issues with compliance included the Worcester Hospital, which had had quite a big renovation in different phases. Fire compliance was being checked and fixed. Tygerberg Hospital was having remedial work and fire compliance. Every new facility needed a fire certificate in the case of electrical upgrading and engineering, and 52 hospitals had been involved in this process.

Ms Windvogel asked about page 116 and the preferential procurement policy. What had caused the delays, and how long had it been in progress?

The Chairperson asked if the resolution could be put to the Department in its entirety and once it had listed its procurements, the reasons could be added on.

Ms Esmereldah Isaacs, Chief Director: Supply Chain Management, said she would provide feedback on how policies and legislation would be developed. The Department did not work on its own, but worked in line with legislation. It ensured that it was proactive to address deviations and challenges. There had been quite a lot of contentious issues in 2017 involving the legislation. With the regulations issued, there had been some challenges with their application. The Department must do what was best for citizens. It would use a code of good policy or the relevant code of good practice, which meant it did not need to apply a preferential policy. It meant that broad-based black economic empowerment (BBBEE) compliance should be implemented as far as possible, and any transactions should be part of the evaluation criteria. Each transaction must get the relevant points for preferential compliance.

In October 2019, which was the year under review, the Provincial Treasury had issued a consolidation of all SCM legislation via Provincial Treasury Instructions (PTIs). This had afforded the Department the opportunity, with a consolidated guideline document, to continue into the development of a policy. Members had to understand that a policy did not necessarily mean it would be implemented. Compliance of the preferential procurement policy regulations was the most important issue of the day.

Ms Bakubaku-Vos said Minister Mbombo’s response was unfair, as she had not pointed out whether the Department was hiring people from communities that were abusers. Her question was what the Department was doing, or what its plan was, to vet the person it would be hiring.

Minister Mbombo said Dr Cloete already responded to this and said that generally, South Africa had the highest number of gender-based violence (GBV) cases, of which sexual harassment was a part. This would be the case in any institution. If nothing had been reported about the person, as well as in the case of senior managers who haf to do psychometric tests, this could still occur. It should be noted that someone could work in an institution for seven years and suddenly change his/her behaviour. It was difficult to predict whether someone would be a thief or a pervert or not. What mattered was that systems were in place to remove someone like this immediately. She was responding generally that South Africa was a sick society.

Dr Cloete reiterated that mechanisms were in place to detect such cases. When someone was employed, a security check was done on the person. If there had been any offence, a check was done before employment was offered. There was a strict process in the Department that was followed for detecting, reporting and investigating such cases. Firm and swift action was taken for any inappropriate behaviour. There was also an awareness programme, for people to follow the process.

Part D -- Human Resource Management (Pages 117-133)

The Chairperson asked Members if there were any questions.

Ms Windvogel referred to page 130 and asked how much the Department paid for seasonal nurses, and the difference in the cost to hire a nurse on a permanent basis. How much had the Department surrendered to the revenue each year? Had it considered approaching the Provincial Treasury for additional funding, even if it was taken from the millions that had been surrendered?

On page 138, what was the reason for the high turnover rate, and what had been done to address this? Was the Department in a position to invest in bursaries and training?

Mr G Bosman (DA) asked for clarity on Ms Windvogel’s question on the funds surrendered in the 2019/20 financial year.

The Chairperson said she understood it, but Mr Bosman said he was still confused and not sure what this question meant.

Ms Windvogel asked if Mr Bosman was the Department, and why he was answering on its behalf.

The Chairperson called Members to order.

Mr Bosman asked the Chairperson to protect him from Ms Windvogel.

Ms Bakubaku-Vos said Mr Bosman was not the Department, and was out of order.

Mr Bosman said he really needed protection now and was very scared.

The Chairperson said Mr Bosman was asking for clarity and Ms Windvogel had clarified what she meant. She would not afford Dr Cloete the opportunity to respond.

Minister Mbombo said the health system in general concerned not only quantity, but skills mix. There were about ten different categories of doctors and nurses. There must be a skills mix with the specialities. People who were specialists, especially when they were older, did not want to be bogged down in permanent jobs. Some medical specialists wanted to be on call, were in the academic space, or had private practices. The people who wanted employment were those who had completed their community service, as they were now released to go anywhere and had to apply for jobs. Not everyone wanted to be permanent, and payment was standardised. This differed according to public and private practice. Members should have a look at the HR plan. The turnover of staff was not high.

Dr Cloete said that on page 128 -- under Nursing and Nursing Information systems -- the last two or three sentences indicated that there were three different types of work: contract workers, interns and registrars. Agency staff were employed on an ad hoc basis when workers were ill or there was a shortage of staff. The agency filled a small gap. The Department would move to a system where it would employ more people and be less dependent on agencies.

Regarding revenue in this year, the Department had over-collected against the target set. Provided it did not overspend on its budget, it had an ongoing relationship with the Provincial Treasury to receive credit for future years on the revenue it had generated. This would be added to its allocation as the Health Department. MTEC was when Treasury met with every department. There was MTEC 1,2 and 3, which resulted in the DoH being able to table a budget with the Committee.

The overall staff turnover was 11.2%, which means that it was only about 1 in 10 people that left the system, which was extremely low. The reasons for resignation were better remuneration or other occupations. Exit interviews were also done in order to have a retention strategy.

Mr Bosman asked if the Department could expand on the Barrett Values survey on Page 124 and indicate whether it planned to conduct another staff satisfaction survey once it had made it out of the COVID-19 period in order to assess the impact on the employees' health and wellbeing. He was encouraged by the last survey and was grateful that many people felt they wanted to work at the Department of Health.

Minister Mbombo said the survey was done annually. There were other ways to evaluate satisfaction. Some concerns had been related to culture and internal relations, but this had changed. When the 2020/21 report was presented, it would be clear that the culture had changed.

Dr Cloete referred to page 39 for the results on surveys, which indicated how the individual experiences in the workplace had dropped from 21% to 18% and 15%. This was an exceedingly positive result for an organisation of the Department's size. Potential limiting values had dropped from four to one and zero in 2019. The value match results were five in 2015 and had gone up to seven in 2017, and stayed at seven in 2021. This value match was extremely high. The Department would continue to use the Barrett Survey.

Ms Windvogel asked if there were plans to increase the number of blacks in the DoH's senior top management, and if the Department had employment equity targets. On page 154, could the Department provide more details on fraud cases and what sanctions had been implemented? What punishments were given for sexual harassment cases?

Minister Mbombo said more theft cases were found, compared to sexual harassment. She understood why Members felt strongly about it, as it was when someone else was wronged.

Dr Cloete said employment equity was promoted in the Department, and it tries everything to attract people of colour, and especially people of African descent, into the most senior positions. It also worked hard to develop internal capacity for people to be promoted.

The Chairperson said this should be made a resolution -- to request the relevant information from the Department.

Ms A Bans (ANC) referred to page 157 and the injuries on duty. She asked for more details on this and whether any cases involved contracting COVID-19. She asked for details on company ownership for each of the private consultants or contractors. What processes had been followed to select the consultants? On page 158, she asked for more information on the legal services rendered.

Dr Cloete said no injuries on duty were related to COVID-19. Details could be found on pages 157 and 158. There was a best practice unit in the country, and the national Department was learning from this Department to try and do the same in other provinces. The unit fights all medico-legal claims put in at the Department. Legal representation ensured that its payouts were not excessive, and it had structured the agreement.

Part E (pages 159 to 163) also dealt with by SCOPA.

The Chairperson asked Members of the public to provide input or raise questions.

She said the Department had been very thorough in its responses. She thanked it and all the stakeholders.  The Committee should confirm the recommendations and resolutions from the Department.

Mr Bosman asked that Members be more specific on what "more information" meant with regard to cases of fraud. A page number and reference should be added.

Ms Bans said she wanted to raise a concern. Mr Bosman had interjected earlier in the meeting with a request for clarity, and this was not right. The Department should respond, not Committee Members. It was the Chairperson’s duty to be asking questions of clarity, and Mr Bosman should not follow-up on questions Members had prepared. Today it would be convenient for Mr Bosman to do this, and tomorrow others would do the same.

The Chairperson said Members should add on where relevant information might have been missed so this information could be obtained from the Department. She believed the Committee had always been very disciplined in its dealings as the Committee. She asked that the Committee respect each others' roles and conduct its business with due diligence and the professionalism it had always displayed.

Ms Windvogel said she agreed with Ms Bans. Members must refrain from answering on behalf of the Department. She had been referring to page 154 when she posed her earlier questions. The Department must know how many fraud cases they had and the details about them.

The Chairperson noted this concern. The APP was quite a thick document, and the Department could not anticipate which questions would be asked, which meant it could not readily answer some questions.

Mr Bosman apologised to Ms Bans and Ms Windvogel, saying he was under the impression that they were all Members of Parliament who worked under the spirit of collegiality. He always learned a lot from Ms Windvogel and had viewed her as an expert on health, which was why he had asked questions of clarity. He did not know that the purpose of these meetings was simply to ask questions and receive answers, but also to ask clarity-seeking questions and expand on one's own knowledge. When he asked clarity-seeking questions, this was because he was really interested and wanted to see what the impact of the question was on his constituents and the committee he chaired. This was not to undermine his colleagues. He always thought they worked well together, and was disappointed that some colleagues felt that they did not learn from each other. He accepted Ms Bans's and Ms Windvogel’s point, and would refrain from engaging with them in future.

The Chairperson said she thought Members should take this in a positive spirit, as all Members had the responsibility to perform oversight and actively participate. She would not entertain the matter any further.

She asked if the resolutions captured the information the Committee wanted to receive from the Department.

Ms Windvogel said she was happy with the resolutions, and she wanted Mr Bosman to know that it was nothing personal, as the Committee learned a lot from him. She wanted to keep a good working relationship, as everyone could learn from each other. Clarity-seeking questions were not a problem -- it was an issue only when Members attempted to answer on behalf of the Department.

The Chairperson asked that the Committee have another look at the resolutions it wanted from the Department when it considered the adoption of the report.

The Chairperson thanked all Members and support staff for their valuable contributions. She encouraged everyone to tell residents to remember to vaccinate and be safe.

The meeting was adjourned.