Department of Health Quarterly performance

Meeting report

The Chairperson opened the meeting and welcomed the Department officials and everyone present. She asked that the Committee observe moment of silence for two nurses, Petronella Benjamin and Ntombizithi Ngidi, who had passed due to COVID-19. She expressed the Committee’s sincere condolences to their families and all their colleagues in the sector.

The Chairperson also informed the Members that they could not ask the officials  on matters regarding COVID-19 as there was an Ad Hoc Committee set up to deal with such issues. This meeting was strictly about the Departments quarterly performance report.

Dr Krish Vallabhjee, Chief Director: Strategy and Health Support, Western Cape Department of Health, asked Members to focus their attention on the PowerPoint slides which the Department had provided together with a spreadsheet. The slides gave a high-level of summary on what the Department’s main issues were. They talked about the number of indicators – what the department had achieved, what was partly achieved and what was not achieved in each of these quarters. They also gave reason as to why indicators were not achieved. The spreadsheet which was handed out focused on data for each of the indicators and showed the data for all four quarters and the full year. The presentation would mainly focus on the PowerPoint slides but Members were welcomed to ask questions if they needed any clarity.

Ms Leslie Shand, Western Cape Department of Health, indicated that the quarter three data that was being presented was final while quarter four data was preliminary. The final data for quarter four would be submitted at the end of May as per guidelines. Quarter three had 68 indicators for this period and 50 of those were achieved – which was 76% of indicators achieved; 24% were partly achieved and three percent were not achieved.

Ms Shand brought Members attention to the first page of the spreadsheet which broke down these according to the programmes they appeared in. Partially achieved indicators were mainly in programme seven, which were HIV/Aids services, STDI’s and Tuberculosis (TB) treatment services. Two of the indicators were in maternal child and women’s health and one from district hospitals. There were also two indicators coming from emergency services; in programme seven and eight, the Department partly achieved targets related to forensic pathology management and health facilities management. Some of the engineering service indicators were not achieved. These quarter three results were similar for quarter four.

The achieved indicators were 76%, partially achieved 21%, three percent not achieved. In terms of programmes, the partially achieved indicators came mostly from programme two which was two indicators in the district health services; two in emergency medical services; one in provincial hospitals; two in central hospitals; one indicator in health science and training; indicators in pathology and health facilities  management were not achieved.

Out of its 104 indicators, the Department was expected to achieve 82 indicators – 79% of them – while19 indicators would be partially achieved and three indicators would not be achieved. The 22 indicators that were currently labeled as partially or not achieving – the Department expected to improve on five of these indicators and achieve the target.

The remaining 17 indicators were unlikely to achieve target for the final data; they were red- flagged in the spreadsheet and the first two were condom distribution and couple year protection rate – both these indicators depended on the condom distribution rate and other factors. The CMD used to push stock to facilities but became overstocked and the Department reverted to a pull system where the facility ordered condoms as they needed them. This facilitated better stock flow management at facilities.  However, the targets of these indicators were set based on the push system of 2019, hence the underperformance.

Medical male circumcision had always been a problem for the Department. This was a demand-driven indicator which meant it was not possible to predict with 100% accuracy the number of people that agreed to do circumcision. The stigma attached to circumcisions remained. There was, however, ongoing work with NPO partners to encourage circumcisions and on a positive note there was a 30% increase in circumcisions in 2019%.

When it came to TB and ART treatment services pretty much the same issues affected these indicators. The challenges included data capturing difficulties, inconsistent use of loss to follow-up list, incorrect addresses and telephone numbers as well as staff turnover. The long treatment period for HIV also impacted retention in care. The province had adopted the 10-point plan of the National Department to address HIV and TB performance and was working with the City of Cape Town and NPO partners to implement these strategies appropriately.  The Department had set up a team to follow up on this process. Another historical challenge for the Department was the antenatal clients starting on ART rate; these were pregnant women that needed to start ART. This was because the clients stopped and then restarted ART but would not be included in the numerator (antenatal clients who start on ART). However, they were included in the denominator (clients eligible for ART); this skewed performance. The Department has addressed the issue with the National Department, and the definition of this indicator was shaded for 2021. This was more of a technical issue than a performance one.

When it came to emergency medical service response, the limited resources in the City of Cape Town continued to affect the performance. However, the Department managed to reduce the overall mission time, specifically in areas such as on scene reduced from 26 to 19 minutes on average and hospital EC turnaround times, but the emergency communication centre dispatch time remained high due to vehicle availability. Some smaller-sized stations in rural areas had been temporarily closed. These stations were unable to roster effective crew optimally but they were being serviced from the nearest bigger station. This allowed for better staff management but in turn affected the response times to far out communities.

The intake of assistant interns for pathology service was also a challenge to the Department; also, an insufficient number of candidates met the minimum educational entrance criteria. Interns also declined due to the nature of work. The indicator on engineering which was looking at the maintenance work done in the Department’s engineering workshops. The reason there was difficulty with this indicator was because of underperformance due to issues with the Western Cape (WC) supplier database and some vacancies in the unit.

In the clinical engineering maintenance indicators, performance was below the threshold due to the backlog in the electronics unit attributed to vacancies – there were three new staff members and one transfer from the dental unit to mitigate vacancy resulting from ill health. These new workers would take some time to achieve acceptable efficiency levels. The dental unit was better able to prioritize work due to more experienced staff to help lessen the impact of their vacancy. Vacancies were advertised but the recruitment processes were delayed due to COVID-19. Delays in replenishment of spares and some repairs started to impact on outputs from mid-January.

The Department had set out to review every child death case in the province through Death Review Boards, but was unable to review every case. Throughout the year, the review boards had not been able to review each case due to the volume of cases and the limited staffing capacity. The partial achievement on pharmaceutical stock was mainly attributed to the late award of tenders by the National Treasury, together with the reduced number of pharmaceutical items within these tenders for which bids were received. Continued poor supplier performance directly affected medicine availability in the reporting period. As of 01 April 2019, the national Department managed the pharmaceutical tender processes as well as the retendering process for items no bids were previously received. Delegates of pharmacy services in the WC were assisting the national Department. The added constraint that became apparent was the effect of the Coronavirus in China and India, with its concomitant lockdown where significant amounts of the active pharmaceutical ingredients (API) was sourced, thus delivery sparse resulting in decreased medicine availability.

The last indicators were under programme eight and the first one was the number of health facilities that have undergone major and minor refurbishment outside NHI pilot district. The work at twelve out of the targeted 26 health facilities planned to undergo the refurbishments was completed. Underperformance was due to slow progress on design stages; delays or extensions of time for projects construction; delays in tender processes for scheduled maintained projects.

The second indicator, budget spend on maintenance, was underperforming mainly due to similar challenges experienced with other indicators under programme eight such as delay in tender processes for scheduled maintenance projects; there were also various challenges with suppliers and contractors in rural areas. These were some of the important indicators that the Department had red-flagged as it would not be able to achieve them within this financial year. The final data would be available only at the end of May but the results of these indicators should stay the same.

Discussion

Ms L Botha (DA) asked about male circumcision and the challenges that the Department had with TB clients and ART. She noticed that the Department had a strategy with the City of Cape Town and enquired whether or not the Department had such a strategy in place with rural municipalities.

Ms R Windvogel (ANC) asked about the staff protest at Tygerberg Hospital relating to COVID-19.

The Chairperson reminded Ms Windvogel that the questions asked should only be informed by what was presented by the officials. Members can use their privileges as Members of Provincial Legislatures to send questions to the Health Minister or the Premier. Questions should be on what officials have presented in the meeting and that was why she would not allow the question; she gave the Member another opportunity to ask a different question.

Ms Windvogel asked with regards to programme eight. Is there work being done to prepare field hospitals as well as quarantine and self-isolation facilities? What is the number of these facilities in the different provinces and how many people are currently admitted to these facilities?

Ms A Bans (ANC) asked about the information on slide four of the presentation. What additional strain has COVID-19 placed on pathology services in the province? Is the Department ready to deal with the mounting death toll? She also asked what the Department was doing to support pathology services during this time. She further asked about the EMS indicator: which stations are closed and where are these stations located in the rural areas?

Ms Botha asked about the challenge the Department had with intake of interns. The Department had not been able to reach its targets because most learners did not meet the minimum requirements - which were having taken mathematics as a grade 12 subject. She asked about the current staff members - if any of them had not matriculated as this was a matter that came up in the last term meeting the Committee had with the Department. Has there been any progress yet in wavering mathematics as requirement? Have there been any discussion happening with the national DoH and the provincial DoH around this matter?

Ms Bans brought attention to slide seven of the presentation and asked which of the indicators were expected to achieve target and what was the reason on the other 17 which were unlikely to achieve target?

Ms Windvogel asked if the Department was continuing with its work to achieve the targets on slide four of the presentation or if it had suspended work due to COVID-19. She also asked if there were any budgets being reprioritized to deal with COVID-19.

The Chairperson enquired about the Department’s strategy for the challenges regarding staff and facilities. What was not adding up was the challenge listed for the EMS staff. Is there a plan of action going forward?

Ms Bans asked for the Department’s projection on the EMS closed station. What are the estimated times and what is the alternative?

Responses

Dr Vallabhjee responded to the question of TB and ART clients. He indicated that the Department was currently having a detailed discussion about patients who fell through the system, especially chronic care patients. This was a province-wide problem and a lot of strategies were being put forward with one of them being the Department’s use of an information system. This system had a unique identification feature which gave each patient a unique identifier and this allowed the DoH to track patients regardless of which facility they were using. This also helped the Department to track patients who were defaulting on their treatment, but there were some data issues such as incorrect phone numbers and addresses which added to the difficulty in tracking patients. The data centre did provide information on patients who were falling through the system. Through its network on the ground working with NPOs and community health workers, the Department managed to follow up visits on these patients and ask them to come back into treatment; this was still a work in progress. There was a need for a system that would allow the Department to retain patients who fell through or fell behind with their treatment.

There was a lot of work being done in relation to getting the facilities ready for COVID-19. She did not bring the specific data of these facilities as they were related to COVID-19 but said she would make the details available to Members but there was work being done on testing center and intermediator care facilities for COVID-19 patients. It was also a bit early to know whether COVID-19 had had an impact on pathology in the province. Forensic pathology dealt with deaths that were deemed unnatural, including COVID-19 deaths; so there was no direct impact on forensic pathology. However, the Chief Director of forensic pathology was working together with local municipalities who had been mandated to deal with COVID-19 burials and death management; there was a lot of work happening in planning for that but the direct hit of COVID-19 was very limited. The issue around the intake and the waiver of mathematics had been raised to the national Department but Dr Vallabhjee was not sure what was discussed and where the issue was currently at; she said she would get back to the Committee with further information on the matter.

Ms Shand indicated that the stations that are closed in rural areas were Bitterfontein, Uniondale, Marisburg and other stations in the Overberg district. She stressed that these stations were not permanently closed or for an extended period; they were just closed because there was insufficient staff and as soon as the staff capacity was back up again then they would be reinstated. This did affect the response time for EMS services as these closed stations were now being serviced by stations in other areas. On the indicators that would not reach target she explained that there was a detailed explanation on each of those on the slide that dealt with indicators that were red-flagged.

Dr Vallabhjee responded on the issue of budgets being reprioritised and said there had been a lot of reprioritising happening due to COVID-19. The Department had been very immersed and focused in dealing with COVID-19 that it had not tracked its other indicators and now had to monitor the impact of non COVID-related issues. The Department resolved that it would look closely at the data for the first quarter and see what the indicators were saying. The Department had also deescalated a lot of its services and put a hold on unimportant surgeries to effectively deal with COVID-19. Dr Vallabhjee said that he did not have the necessary data for the question asked by the Chairperson but said that one of the positive outcomes of COVID-19 was that there had been a decrease in trauma cases, which meant a lot of strain was taken of EMS services. In relation to the last question that was asked by Ms Bans, he said he would get further information from the EMS unit and get back to the Committee.

Closing Remarks

The Chairperson thanked the Department for the briefing and wished the delegation all the best in their task against COVID-19. The Committee also concluded that some of the questions that needed a follow-up would be sent to the Department so it could provide detailed responses on these questions. The procedural officer noted the two resolutions which would be sent to the Department.

Ms Bans asked if the question around the EMS could also be added to the resolutions as she needed more information.

Ms Windvogel also asked that the question – around where the quarantine facilities were located and how many there were in each district – to be added to the resolution.

The Chairperson also asked Members to send the procedural officer an email on their proposed agenda points for the next scheduled meeting as there was no agenda points at the moment.

The meeting was adjourned.